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Race and the Blues

Depression is as prevalent a problem as it is for the population as a
whole, affecting 6% in any year. Within the black community there are
groups whose experience or environment makes them especially vulnerable
to depression and other mental health disorders.

For the 34 million people who identify themselves as African-Americans, depression is as prevalent a problem as it is for the population as a whole, affecting 6% in any year. Within the black community there are groups whose experience or environment makes them especially vulnerable to depression and other mental health disorders.

Yet depression carries such a stigma in the black community that the word is not easily uttered. Nor is the condition readily talked about. One major consequence is that depression is often misunderstood by those who have it, undetected and untreated, perpetuating unnecessary suffering at a time when helpful treatments are available and capable of preventing the long-term damage now thought to result from recurring bouts of depression.

According to an update on the U.S. Surgeon General's groundbreaking 1999 Report on Mental Health , black Americans receive needed mental-health care at a rate only half that of whites. By some accounts, only 7% of black women suffering from depression get any treatment, compared with 20% of the general population.

Shaped by culture as much as by biology, depression in blacks may find expression in symptoms that don't look very much like mood changes, such as fatigue, backache, hypertension or overeating. The disorder is not only disguised in form, it is concealed in language, expressed in terminology definitely not that of the mental health system. "We don't label it depression," observes Pomona, California, psychologist Gloria Morrow, Ph.D.

"We say 'I'm on my last nerve. If you push me any further I'm going to lose it; you're plucking my last nerve,'" explains Baltimore psychiatrist and public health specialist Marilyn Martin, M.D., M.P.H. Martin is author of Saving Our Last Nerve: The Black Woman's Path to Mental Health (Hilton Publishing Co.).

Part of the reason is that blacks feel that they are supposed to put up with all of the burdens placed on them. "Sixty-three percent of blacks see depression as a weakness, a problem only white girls can afford," she reports. "We're supposed to 'bear up.' And if we don't we are being disloyal to our community in general and our aunts and grandmothers in particular."

Of course, blacks also know that owning up to a bona fide mental health problem could be used as one more way to look negatively at them.

Unfortunately, despite disproportionate exposure to trauma, stress and poverty—well established as major precipitants of depression—many blacks themselves have come to believe that they are not subject to depression and don't recognize when they are struggling with it. And, of course, don't seek targeted help that can relieve disorder and prevent recurrences.

Symptoms of depression don't necessarily speak up in the blunt language of mental health either. Sure, there is the classic symptom of sadness. But studies show that up to 50% of all depressed persons don't display depression in emotional terms.

Instead, they report somatic symptoms. And African Americans are especially likely to be among them. Often, neither patient nor doctor is aware of the true source of the problem.

Physical symptoms of depression commonly include chronic or recurring headache, abdominal pain, musculoskeletal pains in the shoulder, neck and lower back. Depression has long been associated with pain. It was once thought that people whose primary symptom was pain were somehow "denying" emotional disorder. The revised view is that somatic complaints are the way some people get depressed; there is a malfunction in the pain perception pathways. Depression is, after all, a disorder of mind and body.

"It's more acceptable to suffer chronic pain than to say you are hurting,"' observes Martin. "In black culture there has long been a contest as to who has suffered more, the black male or black female. I can't go there, as a clinician."

No one knows whether some cultural or neurochemical uniqueness underlies the symptom presentation of major depression in blacks. But subtle neurobiological differences appear to affect the expression of other mental conditions in African Americans.

"There may be cultural universals and cultural specifics," says Carl C. Bell, M.D., professor of psychiatry and public health at the University of Illinois at Chicago. He has, for example, gathered evidence suggesting that blacks have a propensity to auditory hallucinations in bipolar disorder, and that blacks are unusually subject to sleep paralysis.

"I began wondering whether Freud is relevant for us," Bell told Blues Buster . "We need a black psychology." He has spent much of his career attempting to construct it.

Fatigue is a classic accompaniment to depressed mood for many, but especially in black women it may be the only sign of depression. Typically it is not picked up by primary care physicians, who are the main providers of help.

Fatigue is such a cardinal symptom of depression among black women that when West Coast mental health activists recently launched the California Black Women's Health Project to address the prevalence of undiagnosed and untreated emotional distress in their communities, they appropriated as the title for their launch the famous remark of civil rights activist Fannie Lou Hamer: Sick and Tired of Being Sick and Tired.

Anger is another common manifestation of depression in the black community, among women as well as men. "It's more acceptable to be angry than hurt over losses," says Martin.

She sees anger especially among women struggling with a sense of loss and abandonment over not having had a male presence in their early life. "It sets women up to feel negative about themselves, especially if they are not in a relationship," she says. And it leads to difficulty in relationships, playing out powerfully in relationship conflict, a common source of depression among all women.

The high mortality rates for heart disease and stroke and the prevalence of high blood pressure, obesity and diabetes are also traceable to depression, points out Bell. "Stress shows up not only as depression," says Bell. "It also shows up in obesity, hypertension and anxiety disorders."

What's more, it's become clear over the past several years that depression and heart disease don't just frequently co-exist, each leads to the other. Depression makes existing heart disease especially deadly; it also actually spurs the development of coronary artery disease.

African Americans are over-represented in populations that are particularly at risk for mental health problems. A disproportionate number of blacks live in poverty, a potent stressor in itself.

But poverty also contributes to toxic living conditions that supply both adults and children, the most vulnerable members of the population, with multiple forms of adversity. Blacks witness and experience more violence. They require more childhood protective services. "The adverse childhood experiences of blacks lead in adulthood to alcoholism, drug abuse, depression and suicide," says Bell, as well as hypertension, heart disease and obesity.

Mental health problems are definitely not confined to those of low-income status. As African Americans climb the socioeconomic ladder, the stresses on them often shift from more visible external ones to more subtle internal ones, taking their toll on mental health nonetheless.

On the basis of reports from her clients and her own experience, Morrow contends there are huge sources of stress in the workplace, especially for blacks in the upper middle class. Often, they are treated as if they do not deserve to be there. As a result, they feel intense pressure to outperform colleagues, just to gain acceptance.

"Clients are not always aware that these situations of subtle discrimination lie behind depression," says Morrow. "Providers need to be aware."