Major Depressive Disorder in African Americans

Amanda Schwartz

Adeola Ijiyode

Opeletia Helton

Elena Nourabadi

Princess Petrus

University of Tennessee at Chattanooga

 Abstract

Major depressive disorder (MDD) is a chronic mental disorder that can lead to

substantial impairment in an individual’s functionality. Although individuals with depression are

seeking and receiving treatment at an increased rate compared to previous years, a significant

number of individuals with MDD fail to receive proper diagnosis and treatment. The African

American community has a suppressed outlook on mental health and mental health treatment, as

they have less resources available to them and mental health is just not as common a

conversation topic as it is in other communities. This is alarming given that African Americans

are more likely to experience mental health problems compared to other demographic groups

(e.g., Caucasians). Along with MDD in African Americans, this paper will discuss the failure to

properly diagnose in the African American community, service utilization, the barriers in service

utilization and crossing those barriers. The research will prove the disparity between African

Americans and mental health care services and how to combat this disparity. This paper will also

discuss suggested coping mechanisms and what this implies for the African American

community. This paper hypothesizes that young adult African Americans are less likely to seek

and receive treatment for MDD when compared to their demographic counterparts (e.g.,

Caucasians).

Key words: Major Depressive Disorder, African Americans, mental health treatment
 Major Depressive Disorder in African Americans

Mental illness is the leading cause of disability in the U.S. (Mental Health). The rate of

depression has increased over time, either because of increased reporting or just an increasing

acceptance of mental illness as a disability. However, 56% of American adults with a mental

illness do not receive treatment. Along with that, African Americans and Hispanic Americans

each use mental health services at about one-half the rate of Caucasian Americans. Many cases

of mental illness, if left untreated for too long, can lead the individuals to many negative

alternatives, such as drug abuse, alcohol abuse, and even suicide, in an attempt to cope with their

disorder. Ergo, African Americans are at a higher risk for these risk factors, which can lead to

many other crippling life decisions, due to their increased risk for developing depression. It is

important for these disparities to be recognized so that they can be addressed and equal care can

be provided to minorities, African Americans in particular. Therefore, because to the lack of

psychoeducation of mental illness due to cultural norms, an inaccessibility of resources, and a

failure to make resources relatable, we hypothesize that young adult African Americans are less

likely to seek and receive treatment for MDD when compared to other demographic groups (e.g.,

Caucasians).
Major Depressive Disorder

Major depressive disorder (MDD) is defined as having at least five of the following

symptoms present during the same two-week period, either everyday or most days, and as

presenting a change from previous functioning. Symptoms, with at least one of the symptoms

must be either depressed mood or loss of interest/pleasure, include the following: (1) “depressed

mood...as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation

made by others (e.g., appears tearful),” (2) decreased interest/pleasure in all or most activities,

(3) significant weight loss that is not the result of dieting or significant weight gain or significant

increase or decrease in appetite, (4) insomnia or hypersomnia, (5) “psychomotor agitation or

retardation,” (6) “fatigue or loss of energy,” (7) “feelings of worthlessness or excessive or

inappropriate guilt,” (8) “diminished ability to think or concentrate, or indecisiveness,” and/or

(9) recurrent thoughts about or of death, suicidal ideation without a plan, or a suicide attempt or

plan of committing suicide (American Psychiatric Association, 2013, p. 160-161). The

aforementioned symptoms must elicit significant distress or impairment in an individual’s social,

occupational, or other important areas of functioning in order for the individual to be considered

at-risk for MDD. Additionally, the individual’s depressive episode must not be attributable in

any way to the physiological effects of a medical condition or a substance. Some other things

that may exclude someone from having MDD include symptoms not being better explained by

schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, other

specified or unspecified schizophrenia spectrum and other psychotic disorders, having a manic

episode, and/or having a hypomanic episode.

As explained in the Diagnostic and Statistical Manual of Mental Disorders, there are

many different forms of MDD (American Psychiatric Association, 2013). Most broadly, there is
mild, moderate, and severe MDD. MDD can have psychotic features and it can also be

unspecified (American Psychiatric Association, 2013, p. 162). Additionally, MDD can be in

either partial remission (symptoms may still be present but full criteria is no longer met or it has

been less than two months without any significant symptoms of MDD) or full remission (there

has been two or more months with no significant signs/symptoms of MDD; American

Psychiatric Association, 2013, p. 188). MDD can also be further specified as being accompanied

“with anxious distress,” “mixed features,” “melancholic features,” “atypical features,” “mood-

congruent psychotic features,” “mood-incongruent psychotic features,” “catatonia,” “peripartum

onset,” or a “seasonal pattern” (American Psychiatric Association, 2013, p. 162).

Unfortunately MDD is associated with a rather high mortality rate (American Psychiatric

Association, 2013, p. 164-165). Much of this is due in part to lives taken by suicide. However,

the high mortality rate common amongst individuals with depression is also attributed to

depressed individuals’ increased likelihood of death within the first year of admittance into

nursing homes. There is also considerable evidence for “neuroanatomical,

neuroendocrinological, and neurophysical correlates” to MDD but, despite this, no laboratory

test has been developed with a sufficient level of sensitivity in order to test for these

abnormalities/correlates (American Psychiatric Association, 2013, p. 165).

Risk factors for MDD include temperament, environment, genetics and physiology, and

course modifiers (American Psychiatric Association, 2013, p. 166). A major temperamental risk

factor is high neuroticism, or negative affectivity. Environmentally speaking, if an individual had

a particularly difficult or adverse childhood and/or experiences stressful life events, s/he may be

at a greater risk for developing MDD. Additionally, a genetic predisposition to MDD, such as

having a first-degree family member (e.g., parent or sibling) with MDD, may increase an
individual’s risk for developing the disorder two to four times more compared to those with no

first-degree family member with MDD. Having a first-degree family member with MDD also

increases the risk of early-onset and recurrent forms of MDD. Therefore, the heritability of

MDD is approximately 40% with the personality trait of neuroticism accounting for a vast

majority of this genetic predisposition. Finally, if an individual has any other major, non-mood

disorder then s/he is automatically at an increased risk for developing MDD. Unfortunately,

individuals who develop MDD alongside another major, non-mood disorder follow a refractory

course, making their fight against mental illness even harder. The most common comorbid

disorders to depression are substance use, anxiety, and borderline personality disorder as well as

chronic or disabling medical conditions such as diabetes, morbid obesity, and cardiovascular

disease.

Treatment for Major Depressive Disorder

Major depressive disorder, regardless of its severity, can be treated (National Institute of

Mental Health, 2016). As with most other disorders, the earlier the treatment, the better.

Treatments for MDD include medication, psychotherapy, a combination of medication and

psychotherapy, or electroconvulsive therapy (ECT) or other brain stimulation therapies.

Medications for depression are called antidepressants (National Institute of Mental

Health, 2016). Antidepressants work to elevate certain neurotransmitters, such as serotonin or

norepinephrine, in order to help the affected individual be able to better control their mood and

stress. Due to a lack of sufficient and specific neurological testing for measuring

neurotransmitter levels, most people have to try several different antidepressant medications

before finding the one that improves their symptoms and has manageable side effects. Most

psychiatrists will begin with a medication that has helped either the affected individual or a
family member of the affected individual in the past. In addition, antidepressants often take two

to four weeks to take effect and, most commonly, the first symptoms to be alleviated are sleep,

appetite, and concentration problems, not mood. Unfortunately, some people with depression

who are prescribed antidepressants will cease to take their medication once they begin feeling

better and, therefore, enter a toxic cycle of a depressive episode, followed by treatment, followed

by remission, which is then followed by another depressive episode due to them taking

themselves off of their medication. Hence, it is essential for individuals who have depression to

stay on their medication unless otherwise advised by a doctor.

Some of the most effective psychotherapies, or talk therapy, for MDD are cognitive-

behavioral therapy (CBT), interpersonal therapy (IPT), and problem-solving therapy (National

Institute of Mental Health, 2016). CBT emphasizes an individual’s relationship between their

belief systems, emotions, behaviors, what and how the individual thinks, and helps clients to

identify any distortions in their thinking that may be causing them distress (Maniacci, Sackett-

Maniacci, & Mosak, 2014, p. 60). IPT is a form of therapy that emphasizes that the triggers of

depressive episodes lie in disruptions in an individual’s “significant attachments and social roles”

and mainly focus around “grief, interpersonal disputes, role transitions, and interpersonal

deficits” (Verdeli & Weissman, 2014, p. 339). In IPT, the therapist works to resolve these issues

by clarifying with the patient the relationship between the onset of his/her depressive symptoms

and his/her interpersonal problems and by working to build the patient’s interpersonal skills so

that s/he can better manage and resolve these issues. Problem-solving therapy is a form of

therapy that works on teaching clients how to cope with the negative effects associated with

stressful events (American Psychological Association, 2016).

 When neither medication nor therapy nor a combination of the two helps to relieve an

individual’s symptoms, a physician may suggest a brain stimulation therapy such as ECT

(National Institute of Mental Health, 2016). Today’s ECT is very different than the ECT shown

in movies and that of the past. For instance, ECT is typically performed as an outpatient

procedure and occurs in a series of sessions, usually three times per week, for a period of two to

four weeks. Additionally, despite what Hollywood may imply, ECT is not painful and patients

cannot feel the electrical impulses shot through their brains. This is because, prior to the

procedure, patients are placed under a brief anesthetic and given a muscle relaxant in order to

prevent any injuries from the procedure. Then, roughly an hour after the minutes-long procedure,

the patient is alert and awake. Side effects of ECT are often short-term and include confusion,

disorientation, and memory loss. Other brain stimulation therapies include repetitive transcranial

magnetic stimulation (rTMS) and vagus nerve stimulation (VNS).

Other, everyday activities that may help depression include being active, exercising,

setting realistic goals, spending time with others, confiding in a trusted friend or relative,

resisting from isolating oneself, accepting help, expecting one’s mood to improve gradually

rather than immediately, postponing important decisions until the individual is able to discuss

them with someone who knows him/her well and is able to be objective, and psychoeducation

(National Institute of Mental Health, 2016). Major depressive disorder is known to be a risk

factor for cardiovascular disease (CVD). A study conducted by the National Survey of American

Life examined the co-occurrence of MDD and CVD in a nationally represented sample of 2,216

African American Women. The data shows that socioeconomic levels are strongly associated

with every indicator of cardiovascular problems of African American women with and without

MDD (see Appendix A for table showing results from a regression model of comorbidity of
MDD and CVD). For instance, women living in poverty are more likely to experience

cardiovascular problems, excluding a stroke. With those living in poverty, their access to

resources are limited. Therefore, this further stresses the importance of prioritizing daily exercise

for African American women both in poverty and not in poverty who have MDD as it is strongly

associated with several cardiovascular complications.

Depression in African Americans

According to the Health and Human Services Office of Minority Health of Fact Sheet of

2007, African Americans are 20% more likely to experience serious mental health problems than

the general population (2017). One reason for this is that African Americans are more likely to

experience circumstances that merit an increased likelihood of developing mental health issues.

Some of these factors include homelessness, of which African Americans compose 40% of the

homeless population, exposure to violence, overrepresentation of incarcerated populations, foster

care, and child welfare systems. Depression in many African Americans goes undiagnosed due

to stigma, misconceptions, and disbelief in the notion that depression is truly a clinical condition.

Instances such as these further deteriorate one’s mental health when left untreated and increase

the burden of depression in one’s life. According to a study conducted by Williams and

colleagues (2007), when African Americans do suffer from depression, they are more likely to

consider their condition to be severe and disabling, when compared to white Americans

(Williams et al., 2007).

In a study conducted by James (2017), a third-year graduate student who focuses on

racial prejudice and discrimination, it was found that among the African American community

there is a positive relationship between everyday discrimination and risk for past-year MDD. In

the study, James examined the role of self-esteem and low ethnic identities as mediators of the
relationship between internalized racism and past-year MDD of African Americans. James found

that, “internalized racism reinforces the superiority of Whites and maintains a self-perpetuating

cycle of oppression among racial minorities” (James, 2017). When having to embrace

“whiteness” and use Whites’ perspective to outline racial identities, it can lead to negative self-

worth and feelings of intimacy with one’s race or ethnicity (James, 2017).

Another study conducted by Taylor, analyzing the role major depressive disorder plays in

romantic relationships of African Americans. In the Journal of Affective Disorders, a study was

included that examined the relationship between marital and relationship status and 12-month as

well as lifetime prevalence of MDD among African Americans (Taylor et al., year). Data was

collected from an African American subsample of 3570 subjects from the National Survey of

American Life. The World Mental Health Composite International Diagnostic Interview was

used to assess 12-month as well as lifetime MDD. The results (see Appendix B) exemplify a

statistically significant correlation between major depressive disorder and marital/relational

status. It was found that married individuals as well as those cohabitating have the lowest

prevalence of depression out of the three marital statuses. Those that have been previously

married show higher levels of MDD, while those never married nor actively in a relationship

show the greatest odds of 12-month and/or lifetime MDD. These findings indicate that “African

Americans who are depressed are not only less likely to be married; they are also significantly

less likely to be involved in a romantic relationship” (Taylor et al.). Depression may be hindering

the involvement of African Americans in romantic relationships.

Lack of Diagnosis Among African Americans

 When analyzing the mental health of the African American community, it is found that

African Americans are repeatedly underdiagnosed and incompetently managed in primary care.

According to Bailey, Blackmon, and Stevens (2009),

Patient factors include being poor, uninsured, restrictive insurance policies, biological-

genetic vulnerability, non-responsiveness to traditional pharmacological interventions,

and stigma (i.e., attitudes and perceptions of mental illness). Physician factors include

diagnosis and assessment, physician characteristics, physician bias, and culture; and

treatment setting factors include systemic variables such as lack of or poor access to

health care, racism, environment, and patient management.

While examining the severity of depression, a study done by Williams and colleagues (2007)

showed that 56.6% of African Americans compared to 36.8% of Caucasians reported that their

episodes of depressions as being disabling (Copeland et al., 2017). The researchers concluded

that, when African Americans do acquire MDD, it is likely debilitating and persistent. After

conducting a national survey on clinical depression, The National Mental Health Association

reported that approximately 63% of African Americans view mental illness as a “personal

weakness” (Copeland et al., 2017). This mindset, which is different from other cultural groups,

can cause difficulties in efforts for diagnosis. Other key concepts play a role in misdiagnosis of

African Americans. It is found that African Americans are more likely to report physical pain

rather than emotional related symptoms. Washington Journal reports, “data from Robins and

Reiger showed 15% of African Americans showed somatic symptoms compared to 9% of

whites” (Bailey et al., 2009). Other symptoms that African Americans report more than

Caucasians include sleep disturbances, loss of appetite, weight loss, and hypochondriasis.

Limited resources can hinder the the ability to a quality mental evaluation. Additionally,, once
an assessment has been conducted, interpersonal bias can alter the accuracy of the diagnosis.

Unfortunately, such discrepancies occur rather often and should be addressed by developing an

understanding of cultural context in psychiatric diagnosis.

Service Utilization

Notably, African Americans do not have readily available access to mental health

services. In the instance that African Americans do receive treatment from a mental health

professional or establishment, the quality of care is more likely to be poor (2017. In addition to

this issue, research shows that African Americans are less likely to seek treatment for depression.

According to a telephone survey of African Americans, Hispanics, and White Americans,

African Americans were found to be least likely to consider antidepressant medication

acceptable. According to the Mental Health Association survey on African Americans’ attitude

towards depression, only 31% of African Americans believe depression is a “health” problem

(Cooper, et al., 2003). Approximately 30% of African Americans surveyed said they would

“handle” the depression themselves if they were depressed, while 20% said they would turn to

their friends and family for help with depression (Cooper, et al., 2003). Surveys like these reveal

the lack of mental health literacy of African Americans and reinforce the notion that African

Americans are less likely, compared to White Americans, to seek mental health treatment for

depression or to even recognize the severity of the illness (Cooper, et al., 2003).

Barriers to Service Utilization

According to Bussing and Gary (2012), there are numerous health disparities that affect

African-Americans. In general, African-Americans have less access to mental health services

than white and receive poorer qualities of care (Bussing & Gary, 2013). The articles also

describe the barriers in two tiers: systematic and individual. Within the tier of systematic
disparities, the barriers include an underrepresentation of ethnic minority health providers, the

school-to-prison pipeline, and the lack of current clinical research data on ethnic minorities. The

lack of diversity in health providers leads to lack of cultural competence, bias, and misdiagnosis

(Bussing & Gary, 2013, p. 663; National Alliance on Mental Illness, 2017). African-Americans,

due to stigma, are more likely to disclose their physical symptoms related to mental health

problems rather than their emotional symptoms (National Alliance on Mental Illness, 2017).

Culturally incompetent health providers tend to overlook the connection between physical

symptoms and mental health. Additionally, African-American men who display symptoms of

mood disorders or PTSD are often misdiagnosed as having schizophrenia. The school-to-prison

pipeline is perpetuated by the increased use of the zero-tolerance discipline; therefore, minority

youth who display behavioral or learning problems are more likely to be streamlined into school

detention or incarceration rather than receive high quality mental health assessments and

treatments (Bussing & Gary, 2013). The lack of clinical and research data on minorities

contributes to a limit in professional expertise; they aren’t using evidence-based practices for

those clients (Bussing & Gary, 2013, p. 664). In fact, the National Alliance on Mental Illness

(NAMI, 2017) found that, though medications tend to metabolize slower in African-Americans,

they tend to receive higher dosages which increases the chances of negative side effects and

makes the treatment unsustainable.

The National Alliance on Mental Illness thoroughly explains the second tier of barriers,

individual, in their article, African American Mental Health (2017). They first acknowledge

minority communities’ lack adequate information about mental illness which makes it difficult

for them identify their symptoms and know when to seek help (National Alliance of Mental

Illness, 2017). Mental illness in African American communities is seen as either a personal
weakness or a curse from God. They secondly noticed that African Americans tend to rely more

on their churches, family, and friends for emotional support as a treatment for their symptoms

rather than seeking out mental health care providers. The last individual barrier they noticed was

the reluctance and inability of African-Americans to access mental health services. Historical

context of maltreatment from health care providers causes an inherent distrust and, in 2012, 19%

of African-Americans did not have health insurance. Those who do have insurance face the

challenges of high co-pays and deductibles.

Suggestions for Crossing Barriers

It is proven that increasing diversity within the mental health profession “improve[s]

healthcare access for minorities, decrease[s] discrimination, improve[s] patient-provider

communication, and improve[s] quality and satisfaction outcomes” (Bussing & Gary, 2013, p.

664). Mental health professionals who commit to continuing their education improve their

cultural competence and psychological comfort when dealing with minority clients (Bussing &

Gary, 2013, p. 665). Mental health professionals who befriend colleagues from minority

backgrounds increase their understanding of cultural nuances, skills, and anxieties such as

racism. Mental health professionals who participate in volunteer activities in minority

communities come to understand the diverse groups’ norms and practices and decrease stigma.

Mentorship targeted toward those with an interest in primary care is also proven to be effective

since African-Americans are more likely to consult their primary care doctor rather than a mental

health professional. Therefore, the primary care provider needs to be competent enough to

identify the symptoms and refer their client appropriately. Lastly, involvement in professional

advocacy organizations for mental illness helps to increase competency of both providers and

families.
Coping with Major Depressive Disorder

When understanding major depressive disorder, there are many types of coping

mechanisms an individual can perform in order to help aid while undergoing a depressive

episode. Adults may find it difficult to make time for pleasant activities or exercises that can aide

them while enduring an episode due to their daily activities such as work, family, or household

chores. It is with specific daily strategies that make ordinary activities that people with major

depressive disorder find difficult a little easier.

It is beneficial for an individual to find an activity they enjoy and to partake in it. With

depression, it can be extremely hard for an individual to find the motivation to do what they want

to do, rather than what they find productive or comfortable. In other words, it can be easier for

someone to busy themselves with household chores rather than spend time outside or go to a

movie (Rohan, 2009, p. 51). This emphasizes the importance of time management in order to set

aside time to complete responsibilities as well as a pleasant activity. Incorporating pleasant

activities into a daily routine helps to actively better the depressive symptoms one is undergoing.

Having specific coping mechanisms planned out in one’s day can cause encouragement in

completion of prioritized responsibilities when knowing there is time for a pleasant activity to

come at the end. Dr. Kelly Rohan, specialist of psychopathology and treatment of adult mood

disorders, mentions in her book, Coping with the Seasons (2009), “a high frequency of pleasant

activities is associated with satisfaction and happiness; a low frequency of pleasant activities is

associated with depressed moods” (p.51). This is often times played out with those that suffer

from SAD, a seasonal affective depressive disorder. Experiencing states of “cabin fever” is not

uncommon for those that suffer from this. Rohan writes, “during fall and winter, people with
SAD tend to experience fatigue and lack of energy, when they do not feel like doing anything” (

2009, p. 48). The consequence of this absence of activity is increased depression.

Because there are varying types of depression as well as all different types of

personalities and passions, it is crucial to find a coping mechanism that specifically relates to an

individual’s interests. Rohan suggests to learn something new that one has expressed interest in

(2009). Also, performing tasks that causes one to feel skilled can spark a positive mood. A brief

report included in the Journal of Affective Disorders studies how positive social interactions are

encouraged as well as physical activities and exercises (Rohan, 2009, p. 51). When giving these

things a try, individuals often times come across obstacles that hinder their enjoyment associated

with the activity. With MDD, it is not uncommon for individuals to experience a loss of

enjoyment in pleasurable activities. Rohan’s advice is to “fake it until you make it” (Rohan,

2009, p. 49). It is found that, with consistent repetition of the activity, gradual satisfaction will

return. For those that experience fatigue, it is beneficial to talk oneself through it. These

individuals should remind themselves that completing these activities will help their well being

and, that, if they do not follow through with execution of these exercises, they will only be stuck

in the depressive mood. The fatigueness should reduce over time as one gradually completes

more and longer tasks. Emotions can also get in the way of these coping mechanisms. If an

individual experiences anxiety, irritability or discomfort with social situations, this can hinder

their enjoyment with the activity. Even if this is the case, this should not hamper one from

following through with it. Rohan suggests, “identify the source of the emotional discomfort and

work on removing it. If you feel irritable or anxious, find effective ways to relax before doing the

pleasant activity” (Rohan, 2009, p. 52). She advises to not make excuses, but rather remember

that it should become more comfortable the more times the activity is done.
 When advising someone with MDD, it is important to remind them that these pleasant

activities are needed in order to boost their mood. Specifically with the African American

community, exercise is encouraged due to the association between cardiovascular problems and

depression (Bailey et al., 2009). Physical activities are also highly encouraged. For those that

experience difficulty with pursuing a romantic relationship, positive social interactions would be

beneficial in establishing relations with others. Commitment is also crucial as well as readiness

to make life choices and establish priorities in furtherance of bettering one’s life.
 Methodology

The methodology for this paper included searching for empirical sources on scholarly

databases such as PsycInfo and Google Scholar. Then we synthesized the information provided

in these articles and books in order to reach our conclusions. For this paper, we hypothesized that

that young adult African Americans would be less likely to seek and receive treatment for major

depressive disorder compared to other demographic subgroups (e.g., Caucasians).

 Data and Results

Because this is a literature review, we have collected no novel data or results. Therefore,

we have no data or results to report or analyze. However, based on the information suggested by

the empirical articles cited in this paper, we can conclude that the data do support our hypothesis.
 Conclusion and Implications

Based on the stated literature review and analysis of data, African Americans are at a

disparity for mental illnesses, including major depressive disorder. From the years of systemic

oppression and the lack of minorities included in research about mental health care, the mental

health field has failed to adequately address and meet the needs of African Americans. In order

to begin to correct these failures, more holistic research must be tailored to the experiences of

African Americans. Additionally, education in mental health literacy needs to be intentionally

directed towards the African American community.

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 Appendix A

Table 1 shows results from a logistic regression model of comorbidity of Major Depressive Disorder and CVD of
the sample.
 Appendix B

Table 2 shows the results of a weighted logistic regression