Introduction

Psychiatric illness prevalence within the United States, particularly trauma and stress-related disorders, varies by racial and ethnic groups. While racial and ethnic categories are not true biological divisions in humans, individuals are racialized into these groups by virtue of their societal systems which in turn affects mental health. For example, Black individuals typically show lower rates of internalizing disorders such as posttraumatic stress disorder (PTSD), anxiety, and depression compared to White individuals (Breslau et al., 2006; Kessler et al., 2005). Although the prior work highlights race-related differences in the prevalence of posttraumatic dysfunction, limited work to date has investigated racial/ethnic differences in symptoms that present in the early aftermath of trauma. Recent research demonstrates peritraumatic responses to traumatic events may be indicative of later chronic dysfunction or may map onto other discernable trajectories of trauma recovery/deterioration (Bonanno & Mancini, 2012; Galatzer-Levy et al., 2013; Shalev et al., 2019). There is a paucity of research on potential racial/ethnic variability in peritraumatic responses or the trajectories of trauma symptoms in first several months after trauma which may impact the generalizability or accuracy of predictive models of susceptibility to posttraumatic disorders. The purpose of the present analysis is to characterize potential racial/ethnic differences in the trajectories of trauma-related disorder symptoms in the early aftermath of trauma.

Prior epidemiological data suggests that White individuals report greater exposure to any traumatic event and childhood physical abuse compared to Black or Hispanic individuals (Roberts, Gilman, Breslau, Breslau, & Koenen, 2011). Exposure to prior traumatic events is a major predictor of subsequent PTSD development following a later trauma and thus may be related to greater rates of PTSD in White individuals (Gould et al., 2021). However, global epidemiological data highlights that the type of prior traumatic event (such as violence victimization) also influences subsequent PTSD development (Kessler et al., 2018; Liu et al., 2017). Importantly, Black and Hispanic individuals generally experience more childhood adversities, community violence exposure, and exposure to other environmental inequities that impact health (Maguire-Jack, Lanier, & Lombardi, 2019; Sheats et al., 2018; Slopen et al., 2016; Williams & Collins, 2001; Williams, Mohammed, Leavell, & Collins, 2010). Further, Black individuals often have less wealth and lower income compared to White individuals and higher income may afford access to systems that can attenuate the consequences of traumatic events (e.g., healthcare access) and buffer against the financial and social consequences of trauma (Cook, Trinh, Li, Hou, & Progovac, 2017; Herring & Henderson, 2016; Yearby, 2018). As discussed, these types of traumatic experiences are also associated with high conditional risk of PTSD after experiencing a subsequent trauma (Powers, Fani, Cross, Ressler, & Bradley, 2016; Yehuda, Halligan, & Grossman, 2001). Thus, the on-average greater disadvantage experienced by minority group individuals may contribute to greater posttraumatic dysfunction. However, racial/ethnic minority groups generally report a lower prevalence of PTSD (Breslau et al., 2006; Kessler et al., 2005), and thus non-White individuals may in fact show reduced severity of posttraumatic dysfunction in the early aftermath of trauma compared to white individuals. Limited work to date, however, has investigated racial/ethnic differences in posttraumatic symptoms in the early aftermath of trauma.

There is some ambiguity as to whether greater resilience to posttraumatic dysfunction may be present in non-White individuals in the aftermath of trauma (Muralidharan, Austern, Hack, & Vogt, 2016). Some exposures more often experienced by Black and Latinx individuals (e.g., chronic neighborhood disadvantage) are not captured well within the DSM-5 conceptualization of trauma and may be related to lower reports of PTSD-related symptoms. However, a component of commonly reported lower PTSD prevalence rates may be due to underreporting of symptoms in epidemiological surveys or lower healthcare availability or utilization in minority racial groups that impacts survey participation (Cook et al., 2017; Miranda, McGuire, Williams, & Wang, 2008). These may partially explain why some prior research has observed higher rates of undiagnosed PTSD in disadvantaged Black individuals (Davis, Ressler, Schwartz, Stephens, & Bradley, 2008; Parto, Evans, & Zonderman, 2011). In addition, a recent report demonstrated that racial discrimination experienced by Black individuals was a risk factor for future PTSD symptom development after trauma (Bird et al., 2021). Thus, race-related stressors may also exacerbate racial/ethnic differences in early PTSD symptoms.

Early prior research from the AURORA study, a multisite longitudinal study of posttraumatic outcomes (McLean et al., 2019), have identified factors associated with the expression of PTSD and depression symptoms in the early aftermath of trauma such as peritraumatic distress and dissociation, or neurophysiological responses (Harnett et al., 2021; Joormann et al., 2020; Kessler et al., 2020; Steuber et al., 2021). Interestingly, the early AURORA work did not identify robust racial/ethnic differences in posttraumatic symptoms within the first two to eight weeks after trauma. We note however that the prior work did not investigate racial/ethnic variation in posttraumatic stress in further time points (e.g., 3-months after trauma exposure) or potential relationships with structural inequities and prior trauma exposure. Given the dissociation between racial/ethnic variability in posttraumatic stress in the early versus long-term aftermath of trauma, it may be that differences in symptom expression over time start to emerge in later time points (e.g., 3-months posttrauma); however, potential differences in symptom expression have not been examined as of yet. Thus, potential racial/ethnic differences in early trauma outcomes remains unclear. Characterizing potential racial/ethnic differences in posttraumatic syndromes over the first several months after trauma is necessary for the development of precision medicine approaches to identify individuals susceptible to long-term posttraumatic dysfunction.

Therefore, to investigate racial/ethnic differences in posttraumatic symptoms in the first three months after a traumatic event, we analyzed data from the AURORA study. We first compared 2-week, 8-week, and 3-month indices of posttraumatic dysfunction (i.e., PTSD, depression, anxiety, or dissociation symptoms) between White, Black, and Hispanic groups. Based on prior literature, we hypothesized that Black and Hispanic individuals would show lower symptoms of posttraumatic dysfunction over time compared to the White individuals. We then examined if controlling for demographic cofactors (e.g., income and employment) contributed to observed racial differences in posttraumatic symptoms. Finally, we completed follow-up analyses investigating the effect of childhood trauma and other prior traumatic events on observed racial differences in posttraumatic symptoms. The present findings provide insight into the impact of race/ethnic-related differences in pretraumatic stressors on traumatic stress reactions in the aftermath of trauma.

Materials and Methods

Participants

Data from the present analyses were obtained as part of the Freeze 2 psychometric data release of the AURORA Study, a multisite longitudinal study of adverse neuropsychiatric sequelae. Details of the larger AURORA project are described elsewhere (McLean et al., 2019). Briefly, trauma-exposed participants were recruited from Emergency Departments (EDs, n = 29) from across the United States. Trauma was defined as a medical accident requiring admission to the ED, and participants who experienced events such as a motor vehicle collision, high fall (>10 feet), physical assault, sexual assault, or mass casualty incidents were automatically included in the study. Other trauma exposures were also qualifying if: a) the individual responded to a screener question that they experienced the exposure as involving actual or threatened serious injury, sexual violence, or death, either by direct exposure, witnessing, or learning about the trauma and b) the research assistant agreed that the exposure was a plausible qualifying event. Trauma was a necessary inclusion criterion for the present study, and no participants without trauma were included. The psychometric data included 1,618 participants recruited between 09/25/2017 and 06/31/2019, however the present analyses were focused on racial/ethnic differences in the posttraumatic outcomes. Thus, we excluded participants who did not have data on posttraumatic dysfunction (i.e., PTSD, depression, anxiety, dissociation, or resilience symptoms) across all timepoints (n = 645). Participants self-reported their race/ethnicity and were coded into four categories of “Hispanic” (“Hispanic”; n = 106),” “non-Hispanic White (“White”; n = 314),” “non-Hispanic Black (“Black”; n = 510),” and “non-Hispanic other-race (“Other”; n = 43).” For the present analyses, we also excluded participants from the “other” racial category due to small sample size that may impact statistical analyses. In total, 930 participants had completed assessments of all measures of posttraumatic dysfunction at the three timepoints and were included in the present analyses (Table 1). A breakdown of the broad class of trauma-types experienced by each group are presented in Table S1. Note, there were no significant differences in the racial/ethnic make-up of the included versus excluded sample [χ² (2) = 2.34, p = 0.31]. All participants gave written informed consent as approved by each study site’s Institutional Review Board.

Demographic and psychometric data collection

Participant demographic data were collected after admission to the ED which included participant marital status, income, education level, employment, and medication administered within the ED (see Table S2 for medication and Table S3 for full demographic category breakdowns). After discharge, participants’ posttraumatic symptoms were assessed at 2-weeks, 8-weeks, and 3-months after trauma exposure (described below). The 2-week assessment queried participant symptoms in the past 14 days while the 8-week and 3-month assessments queried participant symptoms in the past 30 days. Participants also completed retrospective reports within the ED (past 30 days prior to the trauma) of posttraumatic dysfunction symptoms.

Measures of posttraumatic dysfunction

Participants’ posttraumatic dysfunction was assessed in terms of PTSD, depression, anxiety, and dissociation symptoms. PTSD symptoms were assessed using the PTSD Checklist for DSM-5 (PCL-5) (Weathers, Litz, et al., 2013), a 20-item self-report questionnaire on symptom expression and severity. Depression symptoms were assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Depression instrument from the PROMIS short form 8b (Pilkonis et al., 2011). T-scores were derived from total responses to eight items scored on a Likert scale from 1 (never) to 5 (always). Anxiety symptoms were assessed using four items from the PROMIS Anxiety Bank (Pilkonis et al., 2011). Participants rated how often they felt anxious, worried about things, had trouble relaxing, or felt tense on a scale of 1 (none of the time) to 5 (all or almost all of the time) and the responses were summed to create a total anxiety score. Dissociation was assessed using a modified version of the Brief Dissociative Experiences Survey (Bernstein Carlson & Putnam, 1993). Participants were asked to rate how often they felt that people, objects, or the world around them seemed unreal and how often they felt they were looking through a fog so that people and things seemed unclear on a scale from 1 (none of the time) to 5 (all or almost all of the time). The sum of the two questions was used as an index of dissociation severity. As a contrast to the measures of posttraumatic symptoms, we also assessed participants’ psychological resilience using the Connor Davidson Resilience Scale (CD-RISC) (Connor & Davidson, 2003).

Prior trauma exposure

Prior trauma was assessed using the Life Events Checklist version 5 (LEC-5) (Weathers, Blake, et al., 2013). The checklist assessed prior exposure to traumatic events such as natural disasters, accidents, assaults, etc. that: a) happened directly to the participant, b) were witnessed by the participant, c) the participant learned happened to someone close to them, or d) the participant was exposed to details of it due to their occupation. The LEC-5 was administered during the 8-week assessment. Responses to all questions were summed to derive a prior trauma index. We also indexed childhood trauma via 11 items from the Childhood Trauma Questionnaire – Short Form (CTQ) (Bernstein et al., 2003). Participants were asked to rate how often they experienced maltreatment across five domains (emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect) from a scale of 0 (never true) to 4 (very often true). The CTQ was administered during the 2-week assessment.

Statistical analyses

Statistical analyses were completed using a combination of IBM SPSS Statistics version 24 (Armonk, NY) and the JASP statistical package (https://jasp-stats.org/). Chi-square and univariate analysis of variance (ANOVA) models were completed to assess differences in demographic factors between the racial/ethnic groups. Our initial research questions were focused on racial/ethnic group differences in different posttraumatic outcomes over time. We completed sets of linear mixed-effects models with unstructured covariance matrices to investigate race-related differences in posttraumatic dysfunction measures across the five domains assessed (i.e., PTSD, depression, dissociation, anxiety, and resilience). In Model set A, time (3 levels) and racial/ethnic group (3 levels) were included as fixed factors to assess main effects of racial/ethnic group and differences over time for each measure of posttraumatic dysfunction (five models total). In Model set B, covariates for age, employment status, income, education, marital status, and medication usage during recruitment from the ED were included to determine if race/ethnic differences were observed above and beyond base demographic factors. Demographic data were dummy-coded for inclusion as covariates in linear mixed-effects models (marital status: married vs not; income: <= $35,000 vs > $35,000; education: completed high-school or less, completed greater than high-school; employment: employed vs not; ED medication: yes vs no). Income was dummy-coded based on the median response. We completed separate univariate ANOVAs on assessments completed in the ED to determine if racial/ethnic differences in posttraumatic dysfunction were potentially driven by pre-trauma symptoms. We then repeated Model set A controlling for pre-trauma symptoms and this analysis is reported in the supplement. We next sought to determine if other potential pre-trauma factors may be related to the observed race-related differences in posttraumatic depression and anxiety severity. We focused on prior lifetime and childhood trauma given prior work has demonstrated these factors are major risk factors for subsequent PTSD. The prior trauma index derived from LEC-5 was used in an ANOVA with racial group as the between-subjects factor. To investigate racial/ethnic differences in childhood trauma, subscale scores for the five domains of the CTQ assessing emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect were entered in a multivariate analysis of variance (MANOVA) with a between-subjects factor for racial group. Prior trauma types that differed significantly between the racial/ethnic groups were included in a final linear model as covariates (Model set C). Bonferroni corrections were applied to the linear models based on our a priori interest in the time by racial group interactions and main effects of racial group (2 contrasts per model, 10 total comparisons) and effects were considered statistically significant at an adjusted p = 0.005 (0.05/10) per model set.

Results

Race-related differences in participant characteristics

ANOVA and Chi-squared tests were completed to assess racial/ethnic differences in the demographic factors (Table 1). Significant differences in age and proportions of sex at birth categories were observed between the racial/ethnic groups. No statistically significant difference was observed in employment status for the three groups. Racial/ethnic groups differed in income status, education, marriage status, and ED medication use. Black and Hispanic groups had a greater proportion of participants who were low income, had less than an associate’s degree or equivalent, and were not currently or previously married. Medication usage in the ED was generally higher for Hispanic participants.

Race-related differences in posttraumatic outcomes

Linear mixed-effects models were completed to assess racial/ethnic differences in PTSD, depression, anxiety, dissociation, and resilience scores with and without inclusion of covariates (Table 2). We observed significant main effects of racial/ethnic group on depression and anxiety scores that persisted when accounting for differences in demographic factors. Post-hoc comparisons revealed that Black participants showed lower overall posttraumatic depression and anxiety severity compared to Hispanic and White participants (Table 3). For completeness, exploratory post-hoc comparisons between groups of each measure at each timepoint are presented in the supplement (Table S4). Taken together, these findings demonstrate that the general severity of post-trauma depression and anxiety are lower in recently trauma-exposed Black individuals, and these differences do not appear to be driven by differences in general demographic factors.

We completed follow-up exploratory analyses to investigate if racial/ethnic differences in posttraumatic dysfunction existed prior to ED admission via the retrospective reports. We observed significant main effects of race/ethnicity on depression, dissociation, and anxiety symptoms (Table S5). When the original linear mixed-effects models also included retrospective reports of posttraumatic dysfunction in the ED, we observed significant main effects of race on anxiety symptoms (Table S6; p = 0.028). These findings suggest some aspect of the observed racial/ethnic differences in posttraumatic dysfunction were driven by pre-trauma factors.

Previous trauma exposure and childhood trauma as potential factors

We next investigated racial/ethnic differences in lifetime and childhood trauma as potential pre-trauma factors influencing posttraumatic stress symptoms. We observed a significant main effect of racial group on prior trauma such that White participants endorsed a greater number of traumatic events compared to Hispanic and Black participants (Table 4). Further, we observed a significant omnibus effect of racial group [F(10,1776) = 3.97, p < 0.001, Wilk’s λ= 0.96]. Follow-up univariate ANOVAs revealed race-related differences were specific to emotional abuse, such that White participants reported more emotional abuse compared to Black participants. Of note, prior trauma and childhood emotional abuse were significantly, but weakly, correlated (r = 0.20, p < 0.001).

Given these findings, we repeated the original linear mixed effects models to account for differences in prior trauma and childhood emotional abuse. When accounting for prior trauma and emotional abuse, racial/ethnic group was no longer associated with posttraumatic depression severity or posttraumatic anxiety (Table 2). Taken together, these findings suggest race-related differences in posttraumatic depression and anxiety are partially due to differences in prior reported trauma exposure.

Discussion

Despite evidence of racial/ethnic differences in the chronic and long-term effects of trauma, there are limited data on racial/ethnic differences in posttraumatic outcomes in the early aftermath of trauma. Within the present analyses of a large sample of Hispanic, White, and Black trauma victims, we observed significantly lower posttraumatic depression and anxiety symptoms among Black individuals compared to Hispanic and White individuals. Racial/ethnic differences in depression and anxiety were not attenuated when controlling for differences in socioeconomic indicators or emergency department medication use. However, racial/ethnic differences in posttraumatic symptoms were attenuated when considering differences in prior trauma exposure and childhood emotional neglect. Together, the present findings illustrate that previous exposure to traumatic stress mediates, in part, racial/ethnic differences in depression and anxiety severity in the early aftermath of trauma exposure.

Contrary to our hypotheses, racial/ethnic groups in the present study did not differ in trajectories of recovery from posttraumatic dysfunction over time. Instead, Black individuals displayed – on average – lower severity of depression and anxiety symptoms than Hispanic and White individuals. Prior epidemiological findings suggest that Black and Hispanic individuals have lower occurrence of more chronic disorders such as PTSD and depression (Kessler et al., 2005); however, earlier analyses utilizing data from the AURORA study did not observe racial/ethnic differences in the immediate (i.e., 2-8 weeks) post-trauma phase (Joormann et al., 2020; Kessler et al., 2020). Thus, we initially suspected that racial/ethnic groups would show differing trajectories in symptom severity over time that may explain the discordance between prior research on peri- and- chronic posttrauma outcomes. The lack of a significant time by racial/ethnic group interaction may suggest that differences in recovery trajectory occur at a longer timescale than what was captured in the current analysis (i.e., beyond 3-months). An alternative hypothesis is that posttraumatic dysfunction trajectories are not different between groups, but that differences in the assessment of prevalence rates of chronic dysfunction across racial/groups partially reflects structural inequities. For example, racial/ethnic minority individuals with high symptoms may not be included in these assessments due to confounding factors (e.g., lack of resources) that limit participation. Further analyses within the growing longitudinal AURORA dataset may be able to disentangle posttraumatic trajectories on larger timescales and assess potential attrition related confounds contributing to racial/ethnic differences in posttraumatic outcomes.

Importantly, racial/ethnic differences in posttraumatic depression and anxiety were largely accounted for by differences in prior trauma and childhood emotional abuse. These findings are consistent, in part, with prior work showing that lifetime trauma load is a significant predictor of later PTSD development (Breslau, Chilcoat, Kessler, & Davis, 1999; Kolassa et al., 2010). Further, childhood trauma and adverse childhood experiences are also associated with a range of adult mental health outcomes (McLaughlin et al., 2017; Powers et al., 2016; Schilling, Aseltine, & Gore, 2007). Thus, our data provide support for the model that previous trauma exposures contribute to greater posttraumatic dysfunction after a recent trauma. Somewhat counterintuitively, however, the greater rates of previous trauma were observed in WA participants compared to Hispanic and Black participants. These differences are relatively surprising particularly given the greater amounts of structural adversity (e.g., lower income and education levels) endorsed by Black and Hispanic groups in the present sample.

The disconnect between the present assessment of previous trauma and posttraumatic symptoms and previously observed racial differences in traumatic stress leads to several potentially interesting hypotheses. On the one hand, it should be considered that the current findings may reflect racial/ethnic differences in how individuals from minority groups consider or contextualize events as abuse. Racial/ethnic groups globally and within the US differ in the use and perception of behaviors typically regarded as abusive (e.g., corporal punishment) (Lansford et al., 2015; Taylor, Hamvas, & Paris, 2011). The normalizing of such behaviors may contribute to a hesitancy or inability to consider the events as abusive. As an example, a prior report found that racial/ethnic minority young adults report greater emotional abuse (Brown, Fite, Stone, Richey, & Bortolato, 2018). Further, racial/ethnic minority youth were less able to identify internal feelings as were those with more reported experiences of emotional neglect. These results may suggest that childhood maltreatment contributes to difficulty contextualizing abusive behaviors. Thus, one speculative hypothesis is that the relatively older adults in the present sample are not endorsing events as abusive. On the other hand, the present findings may reflect unique aspects of racialized experiences for White, Black, and Hispanic individuals. Contemporary models of threat and deprivation (McLaughlin, Sheridan, & Lambert, 2014) conceptualize traumatic stressors and abuse as “threats” that are more directly related to the development and expression of posttraumatic symptoms (McLaughlin et al., 2017). Conversely, structural inequalities such as poverty may reflect “deprivation” and this may have greater impacts on future cognitive functioning (Busso, McLaughlin, & Sheridan, 2017). Although cognitive performances were not assessed here, our data may partially support this model in that White individuals experienced more “threat” and minority individuals experienced more “deprivation” and – accordingly – White individuals showed more posttraumatic depression and anxiety symptoms. The relative contributions of such threat-deprivation models to posttraumatic symptoms in the early aftermath of trauma are still relatively unknown and may be one approach to understanding racial/ethnic differences in posttraumatic dysfunction. Speculatively, both of the proposed mechanisms may be relevant to the present results, however it is not possible to disentangle the contributions in the current analyses. Nevertheless, the current findings highlight the need to consider pre-trauma factors that may contribute to race-related differences in peri-and-post-traumatic responses.

Socioeconomic factors such as education and income did not modulate racial/ethnic differences in posttraumatic depression and anxiety. Prior work suggests socioeconomic factors such as education and income moderate the severity of depression and anxiety symptoms and race-related differences in these factors may contribute to racial/ethnic differences in mental health (Chen et al., 2019; Everson, Maty, Lynch, & Kaplan, 2002). Though not the main focus of the present report, we note that income, education, and employment were uniquely associated with PTSD, depression, and anxiety symptoms as well as resilience after trauma exposure. Together, our findings suggest these factors do play a role in posttraumatic responses but do not account for racial/ethnic differences in the early aftermath of trauma.

Several limitations should be noted for the present study. Although our sample is among the largest of longitudinal studies assessing posttraumatic dysfunction immediately following trauma, we were limited in defining racial/ethnic classification to one of three groups. Racial/ethnic variation within the United States is considerably high, and each identity likely has its own stressors that may add nuance to the present results. Future work will be needed to provide more granularity to the present findings. In addition, due to modeling constraints, we only included individuals with complete data on all outcome psychometrics through 3-months after trauma. It is possible that there may be attrition-related interactions with race/ethnicity that we are not able to disentangle here that are relevant for characterizing racial/ethnic differences in posttraumatic outcomes. Another important note is that data were only available for up to three months after the traumatic event. Although we did not observe any differences in changes over time, it is possible that some groups may show significant trajectory changes for periods beyond three months after the traumatic event. It will be necessary to investigate longitudinal changes, ideally leveraging large-scale databases such as the ever-growing AURORA study. However, other datasets from large-scale studies such as the All of Us Research Program (“The ‘All of Us’ Research Program,” 2019), Psychiatric Genomics Consortia (Cichon et al., 2009; Logue et al., 2015), and the Adolescent Brain and Cognitive Development study (Volkow et al., 2018), may also shine important light on the impact of racial/ethnic differences in chronic posttraumatic dysfunction and early childhood pretraumatic factors.

Further, we note that while our approach indexed prior trauma exposure, it is unclear if there were racial/ethnic differences in frequency of specific traumatic events. The LEC-5 was not designed to assess frequency of specific events and although we included a second measure – the CTQ – to improve our index of prior trauma exposure additional research on potential differences in event frequency are needed. Further disentanglement of trauma frequency or proximity to trauma may improve efforts for clarifying individual vulnerability to posttraumatic dysfunction (Weis, Webb, Stevens, Larson, & deRoon-Cassini, 2021). A final limitation is that we did not consider other potentially protective factors in race-related differences of posttraumatic dysfunction. Prior work has highlighted that group differences in behaviors such as religious service attendance may partially explain lower reported mental illness prevalence in Black groups (Reese, Thorpe, Bell, Bowie, & La Veist, 2012). Future work may thus benefit from a consideration of potentially protective factors for race-related differences in posttraumatic dysfunction in the early aftermath of trauma.

In conclusion, the present study demonstrates race-related differences in posttraumatic depression and anxiety are partially driven by racial/ethnic differences in pretraumatic exposures to different life stressors. In particular, White participants’ greater exposure to traumatic events and childhood emotional neglect appeared to potentiate depression and anxiety symptoms after a recent trauma. These findings shed important light on pretraumatic risk factors for posttraumatic dysfunction and provide better understanding of race/ethnicity-related differences in the early aftermath of trauma.

Supplementary Material

Supplement

NIHMS1795430-supplement-Supplement.docx ^{(44.5KB, docx)}

Introduction

The presence of mental health conditions, particularly those related to trauma and stress, varies among different racial and ethnic groups in the United States. While these categories are not based on biological differences, societal systems categorize individuals into racial groups, which then affects their mental well-being. For example, Black individuals often show lower rates of internalizing disorders like post-traumatic stress disorder (PTSD), anxiety, and depression compared to White individuals. While past research highlights these racial differences in chronic trauma-related issues, there has been limited study on how symptoms appear in the immediate aftermath of a traumatic event. Early reactions to trauma may predict long-term difficulties or different paths of recovery. Therefore, this study aims to describe how symptoms of trauma-related disorders change over time in different racial and ethnic groups during the first few months after a traumatic event.

Earlier research suggests that White individuals report more exposure to traumatic events, including childhood physical abuse, than Black or Hispanic individuals. Previous traumatic experiences are a major predictor for developing PTSD after a later trauma, which could explain higher PTSD rates in White individuals. However, the type of prior trauma, such as experiencing violence, also influences later PTSD development. Black and Hispanic individuals often face more childhood adversities, community violence, and other environmental inequalities that affect health. Additionally, Black individuals typically have less wealth and lower income, which can limit access to resources like healthcare that might lessen the impact of trauma. These types of traumatic experiences are linked to a high risk of PTSD after another trauma. Despite experiencing greater disadvantage on average, minority groups generally report a lower prevalence of PTSD. This suggests that non-White individuals might show less severe post-traumatic symptoms in the early period after trauma compared to White individuals, a possibility that has not been widely studied.

There is uncertainty about whether non-White individuals show greater resilience to post-traumatic distress after trauma. Some experiences common among Black and Latinx individuals, such as chronic neighborhood disadvantage, are not fully captured by diagnostic criteria for trauma and may lead to lower reported PTSD symptoms. However, lower reported PTSD rates could also be due to underreporting of symptoms in surveys or less access to healthcare in minority groups, which affects participation in studies. This might explain why some studies have found higher rates of undiagnosed PTSD in disadvantaged Black individuals. Furthermore, recent research shows that racial discrimination experienced by Black individuals is a risk factor for developing PTSD symptoms after trauma. These race-related stressors may worsen racial and ethnic differences in early PTSD symptoms.

Previous research from the AURORA study, a large, ongoing study of post-traumatic outcomes, has identified factors linked to PTSD and depression symptoms in the early aftermath of trauma, such as peritraumatic distress, dissociation, and neurophysiological responses. Interestingly, early AURORA work did not find significant racial or ethnic differences in post-traumatic symptoms within the first two to eight weeks after trauma. However, this earlier work did not examine racial and ethnic differences at later time points, such as three months after trauma, or consider potential links with structural inequalities and prior trauma exposure. Given the discrepancy between early and long-term post-traumatic outcomes across racial and ethnic groups, it is possible that differences in symptom expression emerge at later time points. Therefore, potential racial and ethnic differences in early trauma outcomes remain unclear. Understanding these differences over the first few months after trauma is essential for developing precise medical approaches to identify individuals vulnerable to long-term post-traumatic dysfunction.

To investigate racial and ethnic differences in post-traumatic symptoms during the first three months after a traumatic event, data from the AURORA study were analyzed. The study first compared symptoms of PTSD, depression, anxiety, and dissociation at two weeks, eight weeks, and three months among White, Black, and Hispanic groups. It was hypothesized that Black and Hispanic individuals would show lower symptoms of post-traumatic dysfunction over time compared to White individuals. The analysis then examined whether accounting for demographic factors, such as income and employment, influenced the observed racial differences in symptoms. Finally, follow-up analyses explored the impact of childhood trauma and other prior traumatic events on these racial differences. The findings from this study provide insights into how race and ethnic differences in pre-trauma stressors affect reactions to trauma.

Materials and Methods

Participants

The data for this study came from the AURORA Study, a large, multi-site longitudinal study on negative neuropsychiatric effects after trauma. Participants who experienced trauma were recruited from Emergency Departments (EDs) across the United States. Trauma was defined as a medical accident requiring an ED visit or events like motor vehicle collisions, falls, assaults, or mass casualty incidents. Other exposures also qualified if they were perceived as life-threatening or involved serious injury. From an initial dataset of 1,618 participants, those without complete data on post-traumatic symptoms across all time points were excluded. Participants self-reported their race and ethnicity, categorizing into Hispanic, non-Hispanic White, non-Hispanic Black, and non-Hispanic other-race. Participants from the "other" racial category were excluded due to their small number. In total, 930 participants with complete assessments were included in the analyses. All participants provided written informed consent.

Demographic and psychometric data collection

Participant demographic information, including marital status, income, education level, employment, and medication administered in the ED, was collected upon admission to the ED. After discharge, post-traumatic symptoms were assessed at two weeks, eight weeks, and three months following the trauma. The two-week assessment covered symptoms in the past 14 days, while the eight-week and three-month assessments covered symptoms in the past 30 days. Participants also completed retrospective reports in the ED about post-traumatic symptoms experienced in the 30 days prior to the trauma.

Measures of posttraumatic dysfunction

Post-traumatic dysfunction was evaluated based on symptoms of PTSD, depression, anxiety, and dissociation. PTSD symptoms were measured using the PTSD Checklist for DSM-5 (PCL-5), a 20-item self-report questionnaire. Depression symptoms were assessed with the Patient-Reported Outcomes Measurement Information System (PROMIS) Depression instrument. Anxiety symptoms were measured using four items from the PROMIS Anxiety Bank. Dissociation was assessed using a modified version of the Brief Dissociative Experiences Survey, focusing on feelings of unreality or fogginess. As a contrast to symptoms, psychological resilience was also assessed using the Connor Davidson Resilience Scale (CD-RISC).

Prior trauma exposure

Prior trauma was assessed using the Life Events Checklist version 5 (LEC-5), which evaluates exposure to various traumatic events directly experienced, witnessed, or learned about. This checklist was administered at the eight-week assessment, and responses were summed to create a prior trauma index. Childhood trauma was assessed using 11 items from the Childhood Trauma Questionnaire – Short Form (CTQ). Participants rated the frequency of maltreatment across five areas: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. The CTQ was administered at the two-week assessment.

Statistical analyses

Statistical analyses were performed using IBM SPSS Statistics and JASP. Chi-square and univariate analysis of variance (ANOVA) models were used to compare demographic factors among racial and ethnic groups. Linear mixed-effects models were employed to investigate race-related differences in measures of post-traumatic dysfunction (PTSD, depression, dissociation, anxiety, and resilience) over time. These models first included time and racial/ethnic group as fixed factors. A second set of models added covariates for age, employment status, income, education, marital status, and ED medication use to determine if racial differences persisted beyond these demographic factors. Univariate ANOVAs were also conducted on ED assessments to check for pre-trauma symptoms. Finally, to explore the impact of prior trauma, the prior trauma index from the LEC-5 and subscale scores from the CTQ were included as covariates in the linear mixed-effects models. Bonferroni corrections were applied to account for multiple comparisons.

Results

Race-related differences in participant characteristics

Comparisons using ANOVA and Chi-squared tests revealed significant differences in age and sex distribution among the racial and ethnic groups. While employment status did not significantly differ, racial and ethnic groups showed differences in income status, education, marital status, and ED medication use. Black and Hispanic participants had a higher proportion of low-income individuals, those with less than an associate's degree, and those who were not currently or previously married. Hispanic participants generally showed higher medication usage in the ED.

Race-related differences in posttraumatic outcomes

Linear mixed-effects models showed significant main effects of racial/ethnic group on depression and anxiety scores, which remained significant even after accounting for demographic factors. Further analysis indicated that Black participants exhibited lower overall severity of post-traumatic depression and anxiety compared to Hispanic and White participants. These findings suggest that recently trauma-exposed Black individuals experience lower general severity of post-trauma depression and anxiety, and these differences are not explained by general demographic factors. Follow-up analyses exploring retrospective reports of post-traumatic dysfunction prior to ED admission also found significant main effects of race/ethnicity on depression, dissociation, and anxiety symptoms, suggesting that some observed racial differences were influenced by pre-trauma factors.

Previous trauma exposure and childhood trauma as potential factors

The study then examined racial/ethnic differences in lifetime and childhood trauma as potential pre-trauma factors influencing post-traumatic stress symptoms. A significant main effect of racial group was observed for prior trauma, with White participants reporting more traumatic events than Hispanic and Black participants. Further, racial differences were specifically found in emotional abuse, with White participants reporting more emotional abuse compared to Black participants. Prior trauma and childhood emotional abuse were found to be weakly but significantly correlated. When these factors (prior trauma and childhood emotional abuse) were included in the linear mixed-effects models, the racial/ethnic group was no longer associated with post-traumatic depression severity or post-traumatic anxiety. This suggests that racial differences in post-traumatic depression and anxiety are partly due to differences in previously reported trauma exposure.

Discussion

Despite existing evidence of racial and ethnic differences in the long-term effects of trauma, there is limited data on these differences in the immediate aftermath of trauma. This study, involving a large sample of Hispanic, White, and Black trauma victims, found significantly lower post-traumatic depression and anxiety symptoms among Black individuals compared to Hispanic and White individuals. These racial and ethnic differences in depression and anxiety persisted even after controlling for socioeconomic indicators or medication use in the emergency department. However, these differences were reduced when accounting for variations in prior trauma exposure and childhood emotional neglect. Overall, these findings indicate that previous exposure to traumatic stress partially explains the racial and ethnic differences in depression and anxiety severity in the early period following trauma exposure.

Contrary to the initial hypothesis, the racial and ethnic groups in this study did not show different patterns of recovery from post-traumatic dysfunction over time. Instead, Black individuals consistently displayed, on average, lower severity of depression and anxiety symptoms than Hispanic and White individuals. This contrasts with some earlier AURORA study analyses that did not find racial or ethnic differences in the immediate post-trauma phase. The absence of a significant interaction between time and racial/ethnic group may suggest that differences in recovery patterns emerge over a longer period than the three months observed in this study. Another possibility is that structural inequities, such as lack of resources, may lead to underrepresentation of high-symptom individuals from minority groups in these assessments, influencing reported prevalence rates of chronic dysfunction.

Crucially, racial and ethnic differences in post-traumatic depression and anxiety were largely explained by differences in prior trauma and childhood emotional abuse. This aligns with previous research showing that the accumulation of lifetime trauma is a strong predictor of later PTSD development, and childhood trauma is linked to various adult mental health outcomes. Thus, this study supports the idea that earlier traumatic experiences contribute to greater post-traumatic dysfunction after a recent trauma. Interestingly, White participants reported higher rates of previous trauma compared to Hispanic and Black participants, which is somewhat unexpected given the greater structural adversity (e.g., lower income and education) often experienced by Black and Hispanic groups in the sample.

The discrepancy between the current findings on previous trauma and post-traumatic symptoms and previously observed racial differences in traumatic stress raises several interesting hypotheses. It is possible that these findings reflect racial and ethnic differences in how individuals from minority groups perceive or define events as abuse, as cultural contexts can influence the recognition of abusive behaviors. Alternatively, the findings might reflect unique racialized experiences for White, Black, and Hispanic individuals. Models of "threat" and "deprivation" suggest that traumatic stressors and abuse (threats) are more directly related to post-traumatic symptoms, while structural inequalities like poverty (deprivation) might have a greater impact on cognitive functioning. In this study, White individuals experienced more "threat" and minority individuals experienced more "deprivation," which might explain why White individuals showed more post-traumatic depression and anxiety symptoms. The relative contributions of these models to early post-traumatic symptoms require further investigation.

Socioeconomic factors such as education and income did not explain racial or ethnic differences in post-traumatic depression and anxiety. While previous work suggests these factors can influence the severity of depression and anxiety, and racial differences in these factors may contribute to mental health disparities, this study found they did not account for the racial and ethnic differences in the immediate aftermath of trauma. However, income, education, and employment were individually associated with PTSD, depression, anxiety symptoms, and resilience, indicating their general role in post-traumatic responses.

Several limitations of this study should be acknowledged. While the sample size is large for a longitudinal study of immediate post-trauma dysfunction, racial and ethnic classifications were limited to three groups, potentially overlooking important variations within these broad categories. Due to modeling requirements, only individuals with complete data through three months post-trauma were included, which means potential attrition-related interactions with race/ethnicity could not be fully explored. Additionally, data were only available for up to three months after the traumatic event. It is possible that significant trajectory changes for some groups might occur beyond this timeframe. Future research using larger, longer-term datasets, such as the growing AURORA study or other large-scale programs, will be essential to investigate these longitudinal changes and the impact of early childhood pre-traumatic factors.

Furthermore, while the study indexed prior trauma exposure, it did not clarify if there were racial and ethnic differences in the frequency of specific traumatic events. The tools used were not designed to assess event frequency, highlighting a need for further research on potential differences in trauma frequency or proximity to trauma to better understand individual vulnerability. Finally, the study did not consider other potential protective factors that could influence race-related differences in post-traumatic dysfunction, such as religious service attendance, which has been linked to lower reported mental illness in Black groups. Future work could benefit from considering these protective factors.

In conclusion, this study demonstrates that race-related differences in post-traumatic depression and anxiety are partly driven by racial and ethnic differences in prior exposure to various life stressors. Specifically, greater exposure to traumatic events and childhood emotional neglect among White participants appeared to worsen depression and anxiety symptoms after a recent trauma. These findings offer important insights into pre-traumatic risk factors for post-traumatic dysfunction and enhance the understanding of race and ethnicity-related differences in the early period following trauma.

Supplementary Material

Introduction

Mental health conditions, especially those related to trauma and stress, vary among different racial and ethnic groups in the United States. While race and ethnicity are social constructs rather than biological differences, the way society categorizes individuals into these groups impacts their mental health. For instance, Black individuals often report fewer internalizing disorders like posttraumatic stress disorder (PTSD), anxiety, and depression compared to White individuals.

Previous research shows these race-related differences in chronic post-trauma issues. However, limited studies have looked into how symptoms appear immediately after a traumatic event. Recent findings suggest that responses right after a trauma may indicate whether someone will develop long-term problems or follow different paths of recovery or decline. There is a lack of research on potential racial and ethnic variations in these early responses or how trauma symptoms change in the first few months after an event. This gap in knowledge can affect how broadly or accurately models predict who is likely to develop post-trauma disorders.

This study aims to describe possible racial and ethnic differences in how trauma-related symptoms progress in the initial period following a traumatic event.

Earlier data indicates that White individuals tend to report more exposure to any traumatic event and to physical abuse during childhood compared to Black or Hispanic individuals. Experiencing past traumatic events is a significant predictor of developing PTSD after a new trauma, which might contribute to higher PTSD rates in White individuals. However, global data also highlights that the type of prior traumatic event, such as being a victim of violence, influences whether PTSD develops later.

It is important to note that Black and Hispanic individuals generally face more childhood hardships, community violence, and other environmental inequalities that affect health. Additionally, Black individuals often have less wealth and lower income than White individuals. Higher income can provide access to resources like healthcare, which may reduce the impact of traumatic events and lessen their financial and social consequences. The types of traumatic experiences often faced by minority groups are also linked to a high risk of developing PTSD after a subsequent trauma. Therefore, the greater disadvantages often experienced by minority groups could lead to more severe post-trauma problems. Despite this, racial and ethnic minority groups generally report a lower occurrence of PTSD. This suggests that non-White individuals might actually show less severe post-trauma problems in the early period after a trauma compared to White individuals. However, few studies have explored these racial and ethnic differences in early post-trauma symptoms.

There is some uncertainty about whether non-White individuals show greater resilience to post-trauma problems following an event. Certain exposures more common among Black and Latinx individuals, such as chronic neighborhood disadvantage, are not well-captured by the standard definition of trauma and might lead to fewer reported PTSD-related symptoms. However, lower reported PTSD rates could also be due to underreporting of symptoms in surveys or less access to healthcare for minority racial groups, which affects their participation in studies. These factors might partly explain why some research has found higher rates of undiagnosed PTSD in disadvantaged Black individuals. Furthermore, recent research has shown that racial discrimination experienced by Black individuals is a risk factor for developing future PTSD symptoms after trauma. This suggests that race-related stressors may also worsen racial and ethnic differences in early PTSD symptoms.

Early work from the AURORA study, a large, ongoing study on outcomes after trauma, has identified factors linked to PTSD and depression symptoms in the period immediately following a trauma. These factors include distress and dissociation experienced during or immediately after the trauma, as well as certain brain responses. Interestingly, this early AURORA research did not find strong racial or ethnic differences in post-trauma symptoms within the first two to eight weeks after a trauma. It should be noted, however, that this previous work did not investigate racial or ethnic variations in post-trauma stress at later time points, such as three months after trauma exposure, or potential connections with systemic inequalities and prior trauma exposure. Given the discrepancy between racial and ethnic differences in post-trauma stress in the early versus long-term aftermath of trauma, it is possible that differences in symptom expression over time begin to appear at later points, for example, three months post-trauma. However, these potential differences in symptom expression have not yet been examined. Therefore, potential racial and ethnic differences in early trauma outcomes remain unclear. Understanding possible racial and ethnic differences in post-trauma conditions over the first few months after trauma is crucial for developing personalized medical approaches to identify individuals prone to long-term post-trauma problems.

To investigate racial and ethnic differences in post-trauma symptoms during the first three months after a traumatic event, data from the AURORA study was analyzed. First, symptoms of post-trauma problems (PTSD, depression, anxiety, or dissociation) at two weeks, eight weeks, and three months were compared among White, Black, and Hispanic groups. Based on existing literature, it was hypothesized that Black and Hispanic individuals would show fewer symptoms of post-trauma problems over time compared to White individuals. Next, it was examined whether controlling for demographic factors, such as income and employment, affected the observed racial differences in post-trauma symptoms. Finally, follow-up analyses explored the impact of childhood trauma and other previous traumatic events on the observed racial differences in post-trauma symptoms. These findings offer insights into how race and ethnic-related differences in pre-trauma stressors influence reactions to trauma after an event.

Materials and Methods

Data for this study came from the AURORA Study, a large, ongoing research project that examines negative brain and mental health outcomes after trauma. Trauma-exposed participants were recruited from emergency departments across the United States. Trauma was defined as a medical incident requiring an emergency department visit, including events like car crashes, serious falls, physical or sexual assaults, or mass casualty incidents. Other traumatic exposures also qualified if individuals reported experiencing the event as involving actual or threatened serious injury, sexual violence, or death, either directly, as a witness, or by learning about it, and if a research assistant confirmed it was a plausible qualifying event. All participants in this study had experienced trauma.

The data included 1,618 participants, but the current analysis focused on racial and ethnic differences in post-trauma outcomes. Therefore, participants who lacked data on post-trauma problems (PTSD, depression, anxiety, dissociation, or resilience symptoms) across all time points were excluded. Participants self-reported their race and ethnicity, categorized as Hispanic, non-Hispanic White, non-Hispanic Black, or non-Hispanic Other. For this analysis, participants in the "other" racial category were also excluded due to their small number, which could affect statistical analysis. In total, 930 participants had complete assessments for all measures of post-trauma problems at three time points. All participants provided written informed consent approved by their study site’s ethics review board.

Demographic information, including marital status, income, education level, employment, and medication given in the emergency department, was collected upon admission. After discharge, participants’ post-trauma symptoms were assessed at two weeks, eight weeks, and three months after the trauma. The two-week assessment covered symptoms in the past 14 days, while the eight-week and three-month assessments covered symptoms in the past 30 days. Participants also retrospectively reported any post-trauma problems experienced in the 30 days before the trauma. Post-trauma problems were measured using questionnaires for PTSD, depression, anxiety, and dissociation symptoms. PTSD symptoms were assessed with a 20-item self-report questionnaire. Depression and anxiety symptoms were assessed using specific items from widely used patient-reported outcome measures. Dissociation was measured using a modified survey asking about feelings of unreality or fogginess. As a contrasting measure, psychological resilience was also assessed. Prior trauma exposure was measured using a checklist of traumatic events experienced directly, witnessed, learned about, or exposed to through occupation. Childhood trauma was assessed using a questionnaire with 11 items covering five areas of maltreatment: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect.

Statistical analyses were performed to examine differences in demographic factors among racial and ethnic groups. Linear mixed-effects models were used to investigate race-related differences in PTSD, depression, dissociation, anxiety, and resilience scores over time, both with and without including other demographic factors as controls. These models considered time and racial/ethnic group as key factors. Additional analyses determined if racial and ethnic differences in post-trauma problems before the trauma might have influenced the results. Childhood trauma and other previous traumatic events were also examined as potential factors influencing post-trauma depression and anxiety severity. Statistical corrections were applied to account for multiple comparisons.

Results

Analyses were conducted to identify racial and ethnic differences in participant characteristics. Significant differences were found in age and the proportion of sexes among the racial and ethnic groups. However, no significant difference was observed in employment status. Racial and ethnic groups differed in income, education, marital status, and emergency department medication use. Black and Hispanic groups had a higher proportion of participants with lower income, less than an associate’s degree or equivalent education, and who were not currently or previously married. Hispanic participants generally received more medication in the emergency department.

Studies of post-trauma outcomes revealed significant overall effects of racial and ethnic group on depression and anxiety scores, even after accounting for demographic differences. Specifically, Black participants showed lower overall post-trauma depression and anxiety severity compared to Hispanic and White participants. These findings indicate that Black individuals, who recently experienced trauma, generally have lower severity of post-trauma depression and anxiety, and these differences do not seem to be caused by general demographic factors.

Further investigation explored whether racial and ethnic differences in post-trauma problems existed before emergency department admission, based on participants' retrospective reports. Significant overall effects of race and ethnicity were observed for pre-trauma depression, dissociation, and anxiety symptoms. When these pre-trauma symptoms were included in the main analyses, racial group continued to show a significant association with anxiety symptoms. This suggests that some of the observed racial and ethnic differences in post-trauma problems were influenced by factors present before the trauma.

Next, lifetime and childhood trauma were examined as potential pre-trauma factors influencing post-trauma stress symptoms. A significant overall effect of racial group was found for prior trauma, with White participants reporting more traumatic events than Hispanic and Black participants. Additionally, a significant overall effect of racial group was observed regarding childhood trauma. Detailed analyses showed that race-related differences were specifically related to emotional abuse, with White participants reporting more emotional abuse compared to Black participants. It was noted that prior trauma and childhood emotional abuse were weakly but significantly related.

Given these findings, the original analyses were repeated to account for differences in prior trauma and childhood emotional abuse. When these factors were considered, the racial/ethnic group was no longer linked to post-trauma depression severity or post-trauma anxiety. These results suggest that race-related differences in post-trauma depression and anxiety are partly due to differences in reported prior trauma exposure.

Discussion

Despite evidence of racial and ethnic differences in the long-term effects of trauma, there is limited data on these differences in the immediate aftermath of trauma. This study, involving a large group of Hispanic, White, and Black trauma survivors, found significantly lower post-trauma depression and anxiety symptoms among Black individuals compared to Hispanic and White individuals. These racial and ethnic differences in depression and anxiety persisted even after accounting for socioeconomic factors or emergency department medication use. However, these differences in post-trauma symptoms lessened when considering differences in prior trauma exposure and childhood emotional neglect. Together, these findings illustrate that previous exposure to traumatic stress partly explains racial and ethnic differences in the severity of depression and anxiety shortly after experiencing trauma.

Contrary to initial expectations, the racial and ethnic groups in this study did not show different patterns of recovery from post-trauma problems over time. Instead, Black individuals generally displayed lower severity of depression and anxiety symptoms than Hispanic and White individuals. Previous population-based studies suggest that Black and Hispanic individuals have a lower occurrence of chronic disorders like PTSD and depression. However, earlier analyses using data from the AURORA study did not find racial or ethnic differences in the immediate phase (two to eight weeks) after trauma. Therefore, it was initially thought that racial and ethnic groups would show different trajectories in symptom severity over time, which might explain the inconsistencies between prior research on immediate and chronic post-trauma outcomes. The absence of a significant interaction between time and racial/ethnic group may suggest that differences in recovery patterns occur over a longer period than what this study captured (beyond three months). An alternative idea is that post-trauma symptom patterns are not different among groups, but that differences in how chronic problems are assessed across racial groups partly reflect systemic inequalities. For example, racial and ethnic minority individuals with severe symptoms might not be included in these assessments due to confounding factors, such as a lack of resources, that limit their participation. Future analyses with the expanding AURORA dataset may help to unravel post-trauma patterns over longer periods and assess potential issues related to participant dropout that contribute to racial and ethnic differences in post-trauma outcomes.

Crucially, racial and ethnic differences in post-trauma depression and anxiety were largely explained by differences in prior trauma and childhood emotional abuse. These findings align with earlier research showing that the total number of lifetime traumas is a significant predictor of developing PTSD later. Furthermore, childhood trauma and adverse childhood experiences are also linked to various adult mental health outcomes. Thus, this data supports the idea that previous trauma exposures contribute to more severe post-trauma problems after a recent traumatic event. Somewhat unexpectedly, however, higher rates of previous trauma were observed in White participants compared to Hispanic and Black participants. These differences are rather surprising, especially given the greater levels of systemic adversity, such as lower income and education, reported by Black and Hispanic groups in this study sample.

The discrepancy between the current assessment of previous trauma and post-trauma symptoms and previously observed racial differences in traumatic stress leads to several intriguing possibilities. On one hand, it should be considered that these findings might reflect racial and ethnic differences in how individuals from minority groups perceive or interpret events as abuse. Racial and ethnic groups, both globally and within the U.S., differ in their use and perception of behaviors typically considered abusive, such as corporal punishment. The normalization of such behaviors might lead to hesitation or an inability to identify events as abusive. For example, one previous report found that racial and ethnic minority young adults reported more emotional abuse. Additionally, racial and ethnic minority youth were less able to identify internal feelings, similar to those with more reported experiences of emotional neglect. These results might suggest that childhood maltreatment contributes to difficulty understanding abusive behaviors. Thus, one speculative idea is that the relatively older adults in this study may not be identifying certain events as abusive. On the other hand, the present findings might reflect unique aspects of racialized experiences for White, Black, and Hispanic individuals. Modern models of threat and deprivation describe traumatic stressors and abuse as "threats" that are more directly linked to the development and expression of post-trauma symptoms. In contrast, systemic inequalities like poverty may represent "deprivation," which might have greater impacts on future cognitive functioning. Although cognitive performance was not assessed here, this data may partially support this model in that White individuals experienced more "threat," and minority individuals experienced more "deprivation." Accordingly, White individuals showed more post-trauma depression and anxiety symptoms. The relative contributions of such threat-deprivation models to post-trauma symptoms in the immediate aftermath of trauma are still relatively unknown and could be an approach to understanding racial and ethnic differences in post-trauma problems. Both proposed mechanisms may be relevant to the current results, though it is not possible to separate their contributions in this analysis. Nevertheless, the current findings emphasize the need to consider pre-trauma factors that may contribute to race-related differences in responses during and after trauma.

Socioeconomic factors such as education and income did not alter racial and ethnic differences in post-trauma depression and anxiety. Previous research suggests that socioeconomic factors like education and income influence the severity of depression and anxiety symptoms, and race-related differences in these factors may contribute to racial and ethnic differences in mental health. Although not the primary focus of this report, it was observed that income, education, and employment were uniquely associated with PTSD, depression, and anxiety symptoms, as well as resilience after trauma exposure. Together, these findings suggest that these factors do play a role in post-trauma responses but do not explain racial and ethnic differences in the immediate aftermath of trauma.

Several limitations of this study should be acknowledged. While the sample is among the largest in longitudinal studies assessing post-trauma problems immediately after trauma, racial and ethnic classification was limited to three groups. Racial and ethnic diversity within the United States is considerable, and each identity likely has its own stressors that could add complexity to these results. Future work will be needed to provide more detailed insights. Additionally, due to modeling restrictions, only individuals with complete data on all outcome measures through three months after trauma were included. It is possible that participant dropout might interact with race and ethnicity, which could be relevant for understanding racial and ethnic differences in post-trauma outcomes, but this could not be fully addressed here. Another important point is that data were only available for up to three months after the traumatic event. Although no differences in changes over time were observed, it is possible that some groups may show significant changes in their symptom patterns over periods longer than three months after the traumatic event. It will be necessary to investigate longitudinal changes, ideally using large databases like the continually expanding AURORA study. However, other large-scale studies could also shed important light on the impact of racial and ethnic differences in chronic post-trauma problems and early childhood pre-trauma factors.

Furthermore, while this approach indexed prior trauma exposure, it is unclear if there were racial and ethnic differences in the frequency of specific traumatic events. The checklist used was not designed to assess the frequency of particular events, and although a second measure for childhood trauma was included to improve the assessment of prior trauma exposure, additional research on potential differences in event frequency is needed. A final limitation is that other potential protective factors in race-related differences of post-trauma problems were not considered. Previous work has highlighted that group differences in behaviors, such as religious service attendance, may partly explain lower reported mental illness rates in Black groups. Future research could benefit from considering these potentially protective factors for race-related differences in post-trauma problems immediately after trauma.

In conclusion, this study demonstrates that race-related differences in post-trauma depression and anxiety are partly driven by racial and ethnic differences in previous exposures to various life stressors. Specifically, White participants’ greater exposure to traumatic events and childhood emotional neglect appeared to increase their depression and anxiety symptoms after a recent trauma. These findings provide important insights into pre-trauma risk factors for post-trauma problems and offer a better understanding of race and ethnicity-related differences in the early aftermath of trauma.

Introduction

Mental health conditions in the United States, especially those related to trauma and stress, vary among different racial and ethnic groups. While race and ethnicity are social groupings rather than biological ones, society places individuals into these categories, which then affects their mental well-being. For example, Black individuals generally show lower rates of internal struggles like post-traumatic stress disorder (PTSD), anxiety, and depression compared to White individuals. Previous research highlights these differences in trauma-related problems, but few studies have looked at racial and ethnic differences in symptoms that appear shortly after a traumatic event. Recent findings suggest that responses right after a trauma can predict long-term issues or different recovery paths. There is little research on how these early responses or the progression of trauma symptoms in the first few months after a trauma might vary by race or ethnicity. This lack of information can affect how well we predict who is likely to develop long-term trauma disorders. This study aims to describe how trauma-related symptoms change over time for different racial and ethnic groups in the early period following a traumatic event.

Earlier studies have indicated that White individuals report being exposed to more traumatic events overall, and more childhood physical abuse, than Black or Hispanic individuals. Experiencing past traumatic events is a major predictor of developing PTSD after a new trauma, which might explain the higher rates of PTSD in White individuals. However, global data also show that the type of past traumatic event, such as being a victim of violence, also influences whether PTSD develops. Significantly, Black and Hispanic individuals often face more challenges during childhood, more exposure to community violence, and other unfair environmental conditions that harm health. Additionally, Black individuals typically have less wealth and lower income than White individuals. Higher income can provide access to resources like healthcare that may lessen the effects of trauma and offer protection against financial and social difficulties. These types of traumatic experiences are associated with a high risk of PTSD after another trauma occurs. Yet, racial and ethnic minority groups generally report lower rates of PTSD. This suggests that non-White individuals might actually experience less severe post-traumatic difficulties in the early period after a trauma compared to White individuals. Still, limited research has explored these racial and ethnic differences in early post-traumatic symptoms.

There is some uncertainty about whether non-White individuals show greater resilience to post-traumatic problems after a trauma. Some experiences more common for Black and Latinx individuals, such as ongoing neighborhood disadvantages, are not well-covered by the standard definition of trauma, which might lead to fewer reported PTSD symptoms. However, part of the commonly reported lower PTSD rates could be due to individuals underreporting symptoms in surveys, or due to less availability or use of healthcare among minority racial groups, which affects who participates in surveys. These factors might partly explain why some past research has found higher rates of undiagnosed PTSD in disadvantaged Black individuals. Furthermore, a recent study showed that racial discrimination experienced by Black individuals was a risk factor for developing future PTSD symptoms after a trauma. This indicates that stressors related to race can also worsen racial and ethnic differences in early PTSD symptoms.

Early research from the AURORA study, a large, ongoing research project looking at trauma outcomes, has identified factors linked to PTSD and depression symptoms shortly after trauma. Interestingly, initial AURORA findings did not identify significant racial or ethnic differences in post-traumatic symptoms within the first two to eight weeks after trauma. It is worth noting that this previous work did not examine racial and ethnic differences in post-traumatic stress at later points, such as three months after trauma exposure, or consider links with structural inequalities and past trauma. Given the differences between racial and ethnic variations in post-traumatic stress in the early period versus long-term, it is possible that differences in how symptoms appear over time start to show up at later points (e.g., three months after trauma). However, these potential differences have not been studied yet. Thus, possible racial and ethnic differences in early trauma outcomes remain unclear. Understanding these potential differences in post-traumatic conditions during the first few months after trauma is crucial for developing personalized medical approaches to identify individuals who are likely to suffer from long-term post-traumatic problems.

To explore racial and ethnic differences in post-traumatic symptoms during the first three months after a traumatic event, this study analyzed data from the AURORA study. The researchers first compared measures of post-traumatic problems (PTSD, depression, anxiety, or dissociation symptoms) at 2 weeks, 8 weeks, and 3 months among White, Black, and Hispanic groups. Based on prior studies, it was expected that Black and Hispanic individuals would show lower symptoms of post-traumatic problems over time compared to White individuals. Next, the study examined whether controlling for demographic factors (like income and employment) influenced the observed racial differences in post-traumatic symptoms. Finally, additional analyses explored how childhood trauma and other prior traumatic events affected the racial differences in post-traumatic symptoms. The findings from this study offer insights into how racial and ethnic differences in stressors experienced before a trauma impact reactions to stress after the event.

Materials and Methods

This study used data from the AURORA Study, a large, ongoing research project looking at mental health outcomes after trauma. Participants were recruited from 29 emergency departments across the United States. A traumatic event was defined as a medical accident requiring an emergency department visit, such as a car crash, a high fall, physical assault, sexual assault, or mass casualty events. Other events also qualified if the individual felt they involved actual or threatened serious injury, sexual violence, or death.

The data included 1,618 participants. However, this study focused on racial and ethnic differences in post-traumatic outcomes. Therefore, participants who lacked data on symptoms of PTSD, depression, anxiety, dissociation, or resilience across all time points were excluded (645 individuals). Participants reported their own race and ethnicity, categorized as Hispanic (106), non-Hispanic White (314), non-Hispanic Black (510), and non-Hispanic "other" race (43). The "other" racial group was also excluded due to its small size, which could affect statistical analysis. In total, 930 participants with complete assessments at all three time points were included. All participants provided written informed consent.

Demographic information, including marital status, income, education level, employment, and medication given in the emergency department, was collected shortly after participants were admitted. After leaving the emergency department, participants' post-traumatic symptoms were assessed at 2 weeks, 8 weeks, and 3 months after the trauma. The 2-week assessment covered symptoms from the past 14 days, while the 8-week and 3-month assessments covered symptoms from the past 30 days. Participants also provided retrospective reports, meaning they reported symptoms they experienced in the 30 days before the trauma while still in the emergency department.

Participants' post-traumatic problems were measured by symptoms of PTSD, depression, anxiety, and dissociation. PTSD symptoms were assessed using the PTSD Checklist for DSM-5 (PCL-5), a 20-item self-report survey. Depression symptoms were measured using the PROMIS Depression instrument. Anxiety symptoms were assessed using four items from the PROMIS Anxiety Bank. Dissociation was measured using a modified version of the Brief Dissociative Experiences Survey, which included two questions about feeling unreal or looking through a fog. As a comparison to post-traumatic symptoms, participants' psychological resilience was also measured using the Connor Davidson Resilience Scale (CD-RISC).

Prior trauma was assessed using the Life Events Checklist version 5 (LEC-5), which asked about past exposure to traumatic events that happened directly to the participant, were witnessed, or learned about. This was completed at the 8-week assessment. Childhood trauma was measured using 11 items from the Childhood Trauma Questionnaire – Short Form (CTQ), which assessed experiences of emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. This was completed at the 2-week assessment.

Statistical analyses were performed to compare demographic factors among racial and ethnic groups. To study racial and ethnic differences in post-traumatic outcomes over time, linear mixed-effects models were used. These models looked at the effects of time and racial/ethnic group on each measure of post-traumatic problems. Additional analyses included factors like age, employment, income, education, marital status, and emergency department medication use to see if these factors explained any observed racial differences. Further analyses explored if pre-trauma symptoms, prior lifetime trauma, and childhood trauma were related to the observed differences. Strict statistical corrections were applied to ensure the reliability of the findings.

Results

The study observed significant differences in several participant characteristics among the racial and ethnic groups. There were differences in age and the proportion of sexes. Employment status did not differ significantly. However, racial and ethnic groups varied in income status, education, marriage status, and emergency department medication use. Black and Hispanic groups had a higher percentage of participants with low income, less than an associate’s degree, and who were not currently or previously married. Hispanic participants generally received more medication in the emergency department.

When examining post-traumatic outcomes, significant differences were found among racial and ethnic groups for depression and anxiety scores. These differences remained even after accounting for demographic factors. Specifically, Black participants showed lower overall severity of post-traumatic depression and anxiety compared to Hispanic and White participants. These findings suggest that recently trauma-exposed Black individuals experience less severe post-trauma depression and anxiety, and that these differences are not explained by general demographic factors.

Further analyses explored if post-traumatic problems existed before emergency department admission, using retrospective reports. Significant racial/ethnic differences were found for depression, dissociation, and anxiety symptoms reported for the period before the trauma. When these pre-trauma symptoms were included in the main analyses, racial differences in anxiety symptoms remained significant. These results suggest that some of the observed racial and ethnic differences in post-traumatic problems were influenced by factors present before the trauma occurred.

The study also investigated racial and ethnic differences in lifetime and childhood trauma, as these can influence post-traumatic stress symptoms. White participants reported a greater number of prior traumatic events compared to Hispanic and Black participants. There were also overall differences among racial groups regarding childhood trauma. Specifically, White participants reported more childhood emotional abuse compared to Black participants. Prior trauma and childhood emotional abuse showed a weak, but significant, correlation.

When the original analyses were repeated, but this time accounting for differences in prior trauma and childhood emotional abuse, the racial and ethnic group was no longer linked to post-traumatic depression severity or post-traumatic anxiety. This indicates that racial differences in post-traumatic depression and anxiety are partly due to differences in past reported trauma exposure.

Discussion

Despite evidence showing racial and ethnic differences in the long-term effects of trauma, there is limited information about these differences in the immediate aftermath of a traumatic event. This study, which included a large group of Hispanic, White, and Black trauma survivors, found that Black individuals experienced significantly lower symptoms of post-traumatic depression and anxiety compared to Hispanic and White individuals. These racial and ethnic differences in depression and anxiety did not disappear when considering socioeconomic factors or medication used in the emergency department. However, when differences in past trauma exposure and childhood emotional neglect were taken into account, the racial and ethnic differences in post-traumatic symptoms were no longer significant. These findings suggest that previous exposure to traumatic stress partly explains the racial and ethnic differences in depression and anxiety severity that appear shortly after a trauma.

Contrary to the study's initial expectations, the racial and ethnic groups did not show different patterns of recovery from post-traumatic problems over time. Instead, Black individuals, on average, consistently displayed lower severity of depression and anxiety symptoms than Hispanic and White individuals. While past studies indicate lower rates of chronic disorders like PTSD and depression in Black and Hispanic individuals, earlier analyses from the AURORA study did not find racial or ethnic differences in the very early phase (2-8 weeks) after trauma. Therefore, the researchers had anticipated that differences in symptom severity might emerge over time. The lack of a significant interaction between time and racial/ethnic group might suggest that distinct recovery patterns appear over a longer period than the three months examined in this study. Another possibility is that structural inequalities might affect who participates in these assessments, potentially influencing observed prevalence rates. Further research with longer follow-up periods in the AURORA dataset may help clarify trauma trajectories and address potential influences from study participation.

Crucially, differences in past trauma and childhood emotional abuse largely explained the racial and ethnic differences in post-traumatic depression and anxiety. These results align with previous research showing that the total number of lifetime traumas strongly predicts later PTSD development. Additionally, childhood trauma and adverse childhood experiences are linked to various mental health outcomes in adulthood. Thus, this study's data supports the idea that experiencing trauma in the past contributes to greater post-traumatic problems after a new trauma. However, it was somewhat surprising that White participants reported higher rates of past trauma compared to Hispanic and Black participants, especially since minority groups in this study faced more disadvantages like lower income and education.

The discrepancy between the current findings on past trauma and post-traumatic symptoms and previously observed racial differences in traumatic stress raises several interesting ideas. It's possible that these findings reflect how individuals from minority groups define or understand events as abuse. Different racial and ethnic groups, both globally and within the U.S., vary in their use and perception of behaviors typically seen as abusive. Normalizing such behaviors might lead to hesitation or an inability to label events as abusive. For instance, some reports indicate that minority youth are less able to identify internal feelings, particularly those with more reported experiences of emotional neglect. This might suggest that childhood mistreatment makes it harder to recognize abusive behaviors. Alternatively, these findings might highlight unique aspects of racial experiences for White, Black, and Hispanic individuals. Modern theories on threat and deprivation suggest that traumatic stressors and abuse are "threats" that directly relate to the development of post-traumatic symptoms. In contrast, structural inequalities like poverty might represent "deprivation," which could have greater impacts on future thinking abilities. This study's data might partially support this model: White individuals experienced more "threats," while minority individuals experienced more "deprivation," and accordingly, White individuals showed more post-traumatic depression and anxiety symptoms.

Socioeconomic factors such as education and income did not account for the racial and ethnic differences in post-traumatic depression and anxiety. Previous research suggests that socioeconomic factors influence the severity of depression and anxiety symptoms, and racial differences in these factors might contribute to mental health disparities. While not the main focus of this study, it was noted that income, education, and employment were individually linked to PTSD, depression, anxiety symptoms, and resilience after trauma. Overall, these findings indicate that while socioeconomic factors play a role in how individuals respond to trauma, they do not explain the racial and ethnic differences observed in the early period after a trauma.

Several limitations of this study should be noted. Although the sample size is large for a longitudinal study assessing post-traumatic problems shortly after trauma, the study was limited to defining racial and ethnic classification into three main groups. The diverse racial and ethnic landscape of the United States means each group likely faces unique stressors that could add further detail to these findings. Additionally, due to study design requirements, only participants with complete data on all outcome measures through three months after trauma were included. It is possible that individuals who dropped out of the study might have different racial or ethnic backgrounds, and this could affect the findings on post-traumatic outcomes. Another important point is that data was only available for up to three months after the traumatic event. While no differences in changes over time were observed within this period, some groups might show significant changes beyond three months. Further, it is unclear if there were racial and ethnic differences in the frequency of specific traumatic events. The tools used were not designed to assess the frequency of specific events, so more research on potential differences in event frequency is needed to better understand individual vulnerability to post-traumatic problems. Finally, this study did not consider other potential protective factors that might influence racial differences in post-traumatic problems. For example, past work has suggested that differences in behaviors like religious service attendance might partly explain lower reported mental illness rates in Black groups.

In conclusion, this study shows that racial differences in post-traumatic depression and anxiety are partly influenced by racial and ethnic differences in past exposure to various life stressors. Specifically, White participants' higher exposure to traumatic events and childhood emotional neglect seemed to increase their depression and anxiety symptoms after a recent trauma. These findings provide important insights into risk factors that exist before a trauma and help improve our understanding of racial and ethnic differences in the early period following a traumatic event.

Introduction

Mental health problems, especially those from stress or past bad events, can be different for people of various racial groups. Studies have often shown that Black adults report fewer mental health issues like sadness or worry than White adults. However, not much has been known about how symptoms show up right after a traumatic event. This study aimed to find out if there are differences in how trauma symptoms appear and change in White, Black, and Hispanic adults during the first three months after a traumatic event. Researchers also wanted to see if things like past bad experiences played a role.

Materials and Methods

This study used information from 930 adults who had gone to emergency rooms across the United States after a traumatic event. These adults identified as White, Black, or Hispanic. Researchers gathered details about these adults, including their past life experiences and how they felt after the trauma. They used surveys to check for symptoms of sadness, worry, feelings of unreality, and signs of post-traumatic stress at 2 weeks, 8 weeks, and 3 months after the event. They also looked at how resilient people felt and their experiences with past traumas, including childhood abuse.

Results

The study found that Black adults generally reported fewer symptoms of sadness and worry after a traumatic event compared to White and Hispanic adults. These differences remained even when considering things like age, income, or schooling. The most important finding was that these differences in sadness and worry were largely linked to how much past trauma a person had experienced. White adults in the study reported more past traumatic events and more childhood emotional abuse compared to Black and Hispanic adults. When researchers took these past experiences into account, the differences in sadness and worry between the racial groups were no longer as clear.

Discussion

This study shows that differences in how sad and worried people feel after a trauma are partly due to different past experiences. For example, White adults in this study reported more past traumatic events and childhood emotional abuse. These past hard times seemed to make their symptoms of sadness and worry worse after a new trauma. The study did not find that symptoms changed differently over time for each racial group; instead, Black adults simply had lower symptoms overall. This suggests that past life stressors are very important in shaping how people react to new traumas, and these factors can differ among racial groups. More research is needed to understand these patterns over longer periods and with a wider range of people.