Online Social Support Groups Geared Towards Preventing and Treating Depression among Black Women Abstract:
Health Disparities and stigma that surround mental health create barriers for patients and impede treatment.5 Depression is not only treated at lower rates in the African-American community, particularly among Black women, but of those who do receive treatment, many don’t receive adequate treatment.14 To expand the awareness of the value of ethnographic–qualitative approaches in collecting rich contextualized data on depressed African American10, creating an online support group for depressed African American women that is both valid and culturally relevant, would enhance compliance with treatment protocols.10 Addressing these challenges for African American women entails four parts: taking care of our mental health should be deemed as acceptable, mental health knowledge (comprehension), accessibility and affordability.15 An online community designed by black women health professionals can help make it acceptable for African Americans to talk about mental health, which includes ongoing conversations across sectors such as places of work, places of worship and the media. The more it is done, the easier it will be. 15 Which leads to our question: Would engagement in online social support groups geared towards preventing and treating depression (at no cost to members), prevent the increase of newly diagnosed cases of depression among adult African American women?
Introduction:
Depression affects about 19 million Americans and is a huge health concern among African Americans — particularly women. Unfortunately, mental health is often stigmatized in the Black community.14 The term “Black” encompasses both African Americans and more recent African and Caribbean immigrants.5 African American communities across the US are culturally diverse, with immigrants from African nations, the Caribbean, Central America, and other countries.6 Although it can impact people from all walks of life, cultural habits and historical experiences, depression seems, to be expressed and addressed differently among Black women.14 Online communities have an effect on participant retention and the effectiveness of automated lifestyle interventions just like geographical communities.18 An active online community might contain user posted stories about overcoming barriers, empathic messages of support for those who are struggling, and celebrations of success18 If we can figure out how effective psychotherapy and social support can be maximized by electronic support groups, it could leverage social support, positive social modeling, and dynamic content to keep users engaged and to support behavior change.18
What is Depression:
Depression also known as ‘Major Depressive Disorder’ or Clinical Depression, is a serious medical condition that affects the mind and body 2 that one in five people will suffer during their lifetime. 4 Impacting more than 350 million people around the world4, Major Depressive Disorder is one of the most common mental disorders in the U.S.2 and is the leading cause of disability worldwide.4 It is associated with increased mortality due to suicide and impaired ability to manage other health issues.1 Current research suggests that depression is caused by a combination of genetic, biological, psychological factors, environmental influences, and childhood or developmental events.2,4 It is generally believed that in most cases it is often caused by the influence of more than just one or two of these factors.4 Major Depression is manifested by a combination of symptoms that interferes with the ability to work, study, sleep, eat and enjoy once pleasurable activities.4 Chronic Major Depression may require a person to continue treatment and monitor lifestyle habits on an ongoing basis.4 Women, young and middle-aged adults, and nonwhite persons have higher rates of depression than their counterparts, as do persons who are undereducated, previously married, or unemployed.1 No two people are affected the same way by depression and there is no "one-size-fits-all" for treatment.2 Not everyone who is depressed experiences every symptom.2 Some people experience only a few symptoms while others may experience many.2 To be diagnosed with Major Depressive Disorder or Clinical Depression, the following symptoms must be present for at least two weeks:
Persistent sadness, anxious, or “empty” mood.2
Feelings of hopelessness, or pessimism.2
Irritability.2
Feelings of guilt, worthlessness, or helplessness.2
Loss of interest or pleasure in hobbies and activities.2
Decreased energy or fatigue.2
Moving or talking more slowly.2
Feeling restless or having trouble sitting still.2
Difficulty concentrating, remembering, or making decisions.2
Difficulty sleeping, early-morning awakening, or oversleeping.2
Appetite and/or weight changes.2
Thoughts of death or suicide, or suicide attempts.2
Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment.2
People who are at increased risk of developing depression include persons with chronic illnesses (eg. cancer or cardiovascular disease), other mental health disorders (including substance misuse), or a family history of psychiatric disorders.1 Among older adults, risk factors for depression include disability and poor health status related to medical illness, complicated grief, chronic sleep disturbance, loneliness, and a history of depression.1
Suicide:
Historically there has been great disparity in rates of reported suicide among African American women and White Women (Chow, Jaffe, & Snowden, 2003).10 The inaccuracies of suicide determination in African American women have been debated by investigators probably due to the underreporting of suicide in African American women (Worthington, 1992).10 Furthermore, other investigators report that suicide rates of African American women are much higher than those reported (Esposito & Clum, 2002; Harmon, Edlund, & Fortney, 2005).10 The gap in reported rates of suicide among African Americans and Whites has shrunk in recent years due to high rates of suicide among African American youth between the ages of 10 and 14, which increased 233% between 1980 and 1995, compared to 120% for White youth in the same year (CDC, 1998).10 Increasing rates of suicide in this population should continue to alert mental health professionals to the great need for accuracies in diagnosing African American women with depression as well as with other mental health disorders (USDHHS, 2001) .10
Post-Traumatic Stress Disorder
Although African Americans make up 13.3% of the US population, 27% of African Americans live below the poverty level compared to about 10.8% of non- Hispanic whites.6 This may explain why adult Blacks are 20% more likely to be reported as having serious psychological distress than adult Whites, making them more likely to meet the diagnostic criteria for post-traumatic stress disorder (PTSD).5 They are also more likely to have feelings of sadness, helplessness and worthlessness compared to adult Whites.5 African Americans are also more likely to be exposed to factors that increase the risk for developing a mental health condition, such as homelessness and exposure to violence. 16 According to the National Institutes of Mental Health, Post Traumatic Stress Disorder (PTSD) is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event.11 The NIMH notes that to be diagnosed with PTSD after a traumatic event, a person must display one or more symptoms from each of the following categories: re-experiencing (e.g., flashbacks), avoidance (e.g., staying away from places associated with the trauma), reactivity (e.g., being easily startled), and changes in cognition or mood (e.g., difficulty remembering the trauma, etc.) .11 However, the NIMH cautions that not every person who is exposed to a traumatic event will develop PTSD, there are risk factors that make a person more likely to develop the disorder.11 One of the risk factors includes being a woman, as women are more likely to develop PTSD than men.11 The National Center for PTSD found that while women have lower exposure to traumatic life events as compared to men, because women are more likely to experience sexual assault and childhood sexual abuse, they may be more likely to experience PTSD.11
For African-American women, gender and race intersect to make them uniquely vulnerable to PTSD.11 African American women experience the same traumas as other women, but at higher rates.11 The research indicates that there is a significant likelihood that African-American women will suffer sexual trauma, and women who are sexually assaulted are four times more likely to experience PTSD than those who are not.11 Domestic violence, also known as intimate partner violence, is also associated with PTSD.11 Although women of all races and economic backgrounds can experience domestic violence, there is some evidence that African-American women may be at higher risk of experiencing domestic violence, along with facing domestic violence at slightly higher or significantly higher rate than other women.11 Research from the Journal of Women’s Health found that low-income African American women who had experienced domestic violence not only had PTSD, but also had “strikingly high levels of PTSD symptoms”.11
Many researchers have made note of the connection between racism and trauma.11 According to a study from the University of Michigan stated, Black people are more likely to experience race-related stressors and oppression that can lead to increased feelings of victimization, which may also increase the risk for PTSD.11 A Harvard study also observed that perceived discrimination, race-related verbal assault and racial stigmatization have been linked to PTSD, and may partially account for the higher conditional risk of PTSD among Black people .11 Although a single life-threatening event motivated by racism qualifies as a trauma, most expressions of racism tend to be less extreme and more frequent events, than events that are typically considered traumatic.11 Thus, most cases of racial trauma are the result of repeated events, just like traumatization that results from ongoing sexual harassment or bullying.11 In these cases, chronic interpersonal events of a distressing nature occur with enough frequency that the victim begins to worry about future distressing events, resulting in hypervigilance, avoidance, and anxiety — all core symptoms of PTSD.11 Trauma is cumulative — the more traumas people experience the more traumatized they become — so even small acts of racism contribute to the traumatic load.11 Black people experience more racism than any other group, so it makes sense that we see more traumatization as a result” .11
In other words, over time, the repeated experience of dealing with the trauma of racism can take a psychological toll on African-American women.11 Researchers from Boston University found that African-Americans who reported experiencing racism had the highest rates of PTSD in the non-white racial groups studied.11 PTSD can affect many areas of a patient’s health.11 Although it is a psychological condition, it can have other impacts as well.11 Recent research has shown that African-American women with PTSD are more likely to experience obesity, disordered eating, and even chronic illnesses such as heart disease and diabetes. Researchers from Harvard found that PTSD was associated with a 90 percent higher risk for type 2 diabetes among African-American study participants. Among African Americans, certain medical symptoms (e.g., hypertension) may represent nontraditional symptoms of depression (Pickering, 2000).10 For these reasons, PTSD should not be taken lightly.11
Postpartum Depression:
Depression is also common in and affects not only the woman but her child as well.1 Postpartum depression is a serious, but treatable medical illness involving feelings of extreme sadness, indifference and/or anxiety, as well as changes in energy, sleep, and appetite.3 Risk factors for depression during pregnancy and postpartum include poor self-esteem, child-care stress, prenatal anxiety, life stress, decreased social support, single/unpartnered relationship status, history of depression, difficult infant temperament, previous postpartum depression, lower socioeconomic status, and unintended pregnancy.1 While many studies exist on the manifestations of postpartum depression among European-American women, few exist which focus solely on African- American women who have had postpartum.13 Preliminary findings by Hall (1996) suggested that there were differences in the manifestation of postpartum depression between African-American women (AAW) and European-American women.13
Logsdon, Birkimer, and Usui (2000) examined the link between social support and postpartum depressive symptoms in African-American women with low incomes in a sample of 57 African-American women.13 They found that symptoms of depression were pronounced in the sample where the participants received more support than they considered important, and that the importance of support was related to symptoms of depression.13 No study was located that elicited the experience of postpartum depression using a qualitative approach.13 The purpose of this study, therefore, was to explore and describe the nature of postpartum among African-American women from their point of view.13 Although their physical needs seem to be met by current medical policy and institutions, their mental health needs may not be recognized.13 At a time when a new mother is most vulnerable, as they are responsible for the care and nurturing of a newborn baby, their homes, themselves, and their families; it seems that African American mothers are reluctant to expose any frailty, thus making it difficult for professionals to provide adequate diagnosis and treatment.13
Shame was also identified in a study by McIntosh (1993), which found that postpartum mothers who had not sought help felt like failures, felt ashamed, felt inadequate, and ultimately were too embarrassed to tell anyone about their inability to cope.13 The McIntosh study did not include any African Americans in the sample. Clearly then, these feelings of embarrassment, shame, and inadequacy may cross racial and ethnic lines.13
In another study, most of the African-American women in this identified their mother as the person most relied upon to provide support.13 The second person was her spouse, followed by sisters, and other friends and neighbors.13 Two African-American women noted that God gave them the major support, and two African-American women said that their children also gave them support.13 The participants spoke of having “too much” support, not having their mothers when they wanted them to be there, and being alone without their family as being stressors.13 For most of the participants it seemed that the support they received was not always adequate nor what they wanted or expected.13 Most of the participants had spouses at home at the time of the Post Partum Depression, but it appears that the spouses’ presence did not buffer the effects of Post Partum Depression.13 Lack of social support was found in the literature to be a major risk factor of Post Partum Depression (O’Hara & Swain, 1996).13 Therefore, having the right kind of support and the support expected seems to be more important.13 Warren (1997) suggested that stressful life events and lack of social support in middle-class African-American women might cause depression.13
Peripartum Depression
Black women may suffer from untreated peripartum depression in silence, because they dismiss their struggles as a normal part of pregnancy and childbirth and not seek care.3 Treatment for depression during pregnancy is essential.3Greater awareness and understanding can lead to better outcomes for women and their babies.3 Like other types of depression, peripartum depression can be treated with psychotherapy , medication, lifestyle changes and supports, or a combination of these.3 In general, the risk of birth defects to the unborn baby are low, and the decision should be made based on the potential risks and benefits.3
Peripartum depression refers to depression occurring during pregnancy.3 One in seven women experience peripartum depression.3 Mothers often experience immense biological, emotional, financial, and social changes during this time.3Some women can be at an increased risk for developing mental health problems, particularly depression and anxiety.3Many women with peripartum depression also experience symptoms of anxiety.3 One study found that nearly two-thirds of women with peripartum depression also had an anxiety disorder. 5 While there is no specific diagnostic test for peripartum depression, it is a real illness that should be taken seriously.3
Up to 70 percent of all new mothers experience the “baby blues,” a short-lasting condition that doesn’t interfere with daily activities and doesn’t require medical attention.3 Symptoms of the “baby blues” may include crying for no reason, irritability, restlessness, and anxiety.3 These symptoms last a week or two and generally resolve on their own without treatment.3 Peripartum depression is different from the “baby blues” in that it is emotionally and physically debilitating and may continue for months or more.3
Many women may suffer in silence, dismissing their struggles as a normal part of pregnancy and childbirth and not seek care.3 Treatment for depression during pregnancy is essential.3 Greater awareness and understanding can lead to better outcomes for women and their babies.3 Like other types of depression, peripartum depression can be treated with psychotherapy (talk therapy), medication, lifestyle changes and supports, or a combination of these.3 In general, the risk of birth defects to the unborn baby are low, and the decision should be made based on the potential risks and benefits.3
Untreated Depression:
Untreated depression is associated with:
high health care utilization, including excessive use of health care resources10
emergency room visits for self-injurious behaviors (Greenberg, & Rosenbeck, 2003) 10
poor quality of life10
negative impact on the economy due to workplace disruptions and high rates of absenteeism and occupational impairment (Wells et al., 2004) 10
family disruptions through separations and divorce10
failure to thrive syndromes in children with mothers who have comorbid depression10
substance abuse disorders (Boyd, 1993; Boyd, Henderson, Ross-Durow, & Aspen, 1997)10
increase in substance use in an attempt to mute the painful affects of trauma-focused depression and substance abuse (Najavits, Weiss, & Shaw, 1999) 10
impairments in functions comparable to common medical conditions (Wells, Klop, Korbe, & Sherbourne, 2000)10
Among African Americans, certain medical symptoms (e.g., hypertension) may represent nontraditional symptoms of depression (Pickering, 2000).10
Untreated peripartum depression is not only a problem for the mother’s health and quality of life, but can affect the well-being of the baby who can be born prematurely, with low birth weight.3 It can also cause bonding issues with the baby and can contribute to sleeping and feeding problems for the baby.3 In the longer-term, children of mothers with peripartum depression are at greater risk for cognitive, emotional, development and verbal deficits and impaired social skills.3 To be diagnosed with peripartum depression, symptoms must begin within four weeks following delivery.3However, symptoms of depression may occur at any time.3
Moreover, in a recent report of the U.S. Surgeon General (U.S. Department of Health and Human Services [USDHHS], 2001), African Americans are reported to have reduced access or no access to both mental health and health service facilities (Chow, Jaffee, & Snowden, 2003) when compared to other groups, and even when given access, they are less likely to receive the help they need, including antidepressant medications for depression (Melfi, Croghan, Hanna, & Robinson, 2000), despite their willingness to participate in mental health counseling (Blazer, Hybels, Simonsick, & Hanlon, 2000).10
Screening for Depression:
The American Academy of Family Physicians recommends screening for depression in the general adult population, including pregnant and postpartum women.1 Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.1 The American Academy of Pediatrics recommends that pediatricians screen mothers for postpartum depression at the infant’s 1-, 2-, and 4-month visits.1 The American College of Preventive Medicine recommends that primary care clinicians screen all adults for depression and that all primary care clinicians should have systems in place, either within the primary care setting itself or through collaborations with mental health professionals, to ensure the accurate diagnosis and treatment of this condition.1 The American College of Obstetricians and Gynecologists recommends that clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms.1 The Institute for Clinical Systems Improvement recommends that clinicians use a standardized instrument to screen for depression if it is suspected based on risk factors or presentation.1
Commonly used depression screening instruments include the Patient Health Questionnaire (PHQ) in various forms and the Hospital Anxiety and Depression Scales in adults, the Geriatric Depression Scale in older adults, and the Edinburgh Postnatal Depression Scale (EPDS) in postpartum and pregnant women.1 All positive screening results should lead to additional assessment that considers severity of depression and comorbid psychological problems (eg, anxiety, panic attacks, or substance abuse), alternate diagnoses, and medical conditions.1 The optimum interval for screening for depression is unknown; more evidence for all populations is needed to identify ideal screening intervals.1 A pragmatic approach in the absence of data might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted.1 In January 2016, the U.S. Prevention Services Task Force updated its recommendation for depression screening in adults to include screening pregnant and postpartum women.3
Moreover, multicultural assessments of instruments, procedures applied and general cross-cultural sensitivity and ethics should be embraced by researchers and clinicians in the field of mental health (Horton, Carrington, & Lewis- Jack, 2001).10 Carrington and Maultsby (1998) developed a self-help treatment manual for low- income African American women with comorbid major depression and cocaine abuse—a common comorbidity of psychiatric inpatients on a psychiatric acute unit (Carrington, Strickland, & Andre, 1997), and compared group cognitive therapy and group milieu therapy on an inpatient psychiatric unit of an urban hospital over a 5-year period.10 Depressed African American women exposed to manualized cognitive group therapy had significantly lower depression scores and lower rates of relapse than depressed African American women exposed to milieu therapy (Carrington & Maultsby, 1998).10 Proper screening and follow through with quality assessments that utilize a bio-psychosocial model will help practitioners gather unabridged evaluations of their patients. 5 This, in turn, will enable them to find the most appropriate diagnosis for their patients.5 Screenings must be coupled with appropriate follow-up and treatment when indicated (practices should be prepared to initiate medical therapy, refer patients to appropriate care, or both), and systems should be in place to ensure follow-up for diagnosis and treatment.1 The Institute for Clinical Systems Improvement recommends that clinicians use a standardized instrument to screen for depression if it is suspected based on risk factors or presentation.1
Research Trials and Studies:
One of the greatest barriers to keeping Black women from receiving treatment for depression is a history of discrimination and a deep mistrust of health care institutions in the U.S., which can cause Black women to refuse help when they need it.14 A history of trauma and victimization experienced by African-Americans has also helped foster a cultural mistrust and attitudinal barriers toward the U.S. health care system14, that can prevent patients from even seeking treatment in the first place.5 Some of this apprehension is born from cultural mistrust that can be linked to the Tuskegee project.5 This U.S. government funded project continues to be a factor negatively influencing Blacks’ willingness to enter research studies, leading to underrepresentation.5 Events like the Tuskegee Experiments are hypothesized to contribute to many Black people’s negative attitudes about health care. 14 High levels of cultural mistrust have also been linked to a negative stigma of mental illness in the African American community.14
Historically, African American women have not been included in large controlled trials (Weissman, Bruce, Leaf, Florio, & Holzer, 1991) in sufficient numbers to generate data that are generalizable to larger populations of African American women.10 When they have been included in controlled outcome studies in greater numbers (Breslau, Peterson, Poisson, Schultz, & Lucia, 2004) their outcome data has not been analyzed separately.10 Although it is important to study racial differences in treatment outcomes, differences between White/Caucasian Americans and Black/African Americans are not typically studied.10 When they are reported, the researchers have usually made post hoc comparisons based on samples that are not equally representative of the groups being compared.10
Mistrust Between Clinician and Patient:
Mental health care is marginalized within the healthcare system and is not usually a component of annual primary care visits. 15 Medical practitioners often say they don’t have enough time, there are not enough mental health care providers and the trends in medical training reveal that there will be even fewer psychiatrists than we need in the near future (since more than 50 percent of psychiatrists and more than a third of psychotherapists are over the age of 60). 15
Communication between patients and clinicians is considered as critical to assist depressed African American women in changing assumptions about and attitudes toward complying with prescribed medications to treat their depression.10 Research shows that African-American women’s use of mental health services may also be influenced by barriers including, poor quality of health care, (limited access to clinicians that are culturally competent), and cultural matching (limited access to work with minority clinicians).14 Mental health professionals cite it as another significant barrier to treatment seeking for African-American women.14 Though PTSD is serious, some Black women may be cautious about seeking help from mental health professionals, particularly if those professionals are white.11 Unfortunately, women of color make up less than 5 percent of psychiatrists, psychologists and social workers available to treat patients.12 Despite barriers to seeking counseling, the good news is that if the patient can overcome those obstacles, Black women are excellent candidates for many of the most effective PTSD treatments.11
For many African Americans who may want to discuss the impact of racism on their mental health and physical well-being, finding a mental health practitioner who is also culturally competent is important to their healing. 15 There are significant inequalities in care, from misdiagnosis to overuse of medications to misunderstanding cultural expressions of mental distress. 15 But it is not easy to find mental health professionals trained in anti-racist practice and other anti-oppressive strategies, especially outside of major urban areas. 15 Only 2 percent of psychiatrists and a little more than 5 percent of psychologists are African American, according to estimates. 15
Access is a central point of contention when thinking about the care of Black psychiatric patients.5 Often communities are not equipped with adequate facilities and services.5 Having to seek treatment outside of the place where you live is an added barrier and provides for another layer of issues related to time, work, and transportation.5 In addition, regional differences are significant in help-seeking behavior for African Americans according to Taylor, Hardison, and Chatters (1996).13 African Americans from the southern United States were more likely to choose kinship networks than were northern African Americans according to these researchers.13 This observation was true also in the present study and is supported by Mays, Caldwell, and Jackson (1996) who found that African-American women living in the south were less likely to use private therapists than women in other regions in the United States.13 Findings of this study may assist mental health clinicians to sensitively assess African-American women for PPD.13
Unfortunately, research has shown lack of cultural competence in mental health care, which results in misdiagnosis and inadequate treatment.16 When meeting with a provider, it is important to ask questions to get a sense of their level of cultural sensitivity, such as whether they have treated other African Americans, received training in cultural competence, and how they plan to take beliefs and practices into account when suggesting treatment. 16
In 2001, the Surgeon General conducted a report on mental health and found that for nonwhites, “The foremost barriers include the cost of care, societal stigma, and the fragmented organization of services.11 Additional barriers include clinicians’ lack of awareness of cultural issues, bias, or inability to speak the client’s language, and the client’s fear and mistrust of treatment” .11The biggest problem is lack of meaningful diversity training among therapists.11 Until recently, clinical psychologists didn’t get much diversity training in their graduate programs, and so they never learned how to work with people of color.11 Now the APA is trying to crack down on this and make sure that the students are getting the training they need, but graduate programs still find many of ways to get around the is requirement, usually because they don’t have faculty qualified to teach diversity issues to students.1 It is estimated that by the year 2052, nearly half the entire U.S. population will be composed of ethnic and racially diverse people.10 With this growing rate of racial and ethnically diverse groups, clinicians and researchers, as well as the public, will need to understand that the Eurocentric views peculiar to Whites may not be relevant or adequate to address mental health needs among African Americans and other racially diverse groups (USDHHS, 1999).10
Health Knowledge and Comprehension:
Black women are overrepresented in inpatient treatment and underrepresented in outpatient treatment, highlighting the need for more early education and intervention.5 This can be attributed to misdiagnosis and other issues like access of care.5 The reasons for this discrepancy are plentiful: lack of health insurance, distrust of mental health care system, misdiagnosis of symptoms, lack of cultural competence, and stigma.15 Because of the stigma surrounding mental health and depression, there is an extreme lack of knowledge about depression in African-American communities.14 Researchers at Mental Health America find that African-Americans are more likely to believe depression is “normal”.14 In fact, in a study commissioned by Mental Health America on depression, 56 percent of Blacks believed that depression was a normal part of aging.14 In the African American community, people often misunderstand what a mental health condition is and therefore the subject is uncommon. 16 This lack of understanding leads many to believe that a mental health condition is a personal weakness or a form of punishment. 16 Many African Americans have trouble recognizing the signs and symptoms of mental health conditions such as anxiety and depression, which leads to them underestimating the effects of mental health conditions.16
African Americans may also be reluctant to discuss mental health issues and seek treatment because of the shame and stigma still associated with such conditions in their community.16 A report published by the National Institute of Health (NIH) examined Black women’s representations and beliefs about mental illness.14 Researchers cite the low use of mental health services by African-American women and identify stigma as the most significant barrier to seeking mental health services among Blacks.14 Not only do a troubling number of African-Americans not understand depression to be a serious medical condition, but the stereotype of the strong Black woman leads many African-American women to believe that they don’t have the luxury or time to experience depression (some even believe it is only something White people experience).14
Uninsured – SES & Health Insurance:
Social determinants, can affect mental health.5 For Blacks, class and poverty are two impactful factors.5 For example, adult Blacks living below poverty are two to three times more likely to report serious psychological distress than those living above poverty.5 Perhaps more damaging, it can lead some Blacks to be resistant to pharmacological therapies.5 In the United States, not only do we live in a culture that does not support mental health and well-being, it is the only industrialized nation with no national paid maternity leave and no federally required vacation. 15 And for African Americans, the never-ending onslaught of the stress of systemic and personal racism and discrimination — both at the macro and micro levels — exacerbates what regular life in America brings. 15 There’s a strong relationship between socioeconomic status and health such that people at the lower end, people in poverty tend to have poorer health and tend to have fewer resources for dealing with the stressors of life.14 According to the National Poverty Center, poverty rates for Blacks greatly exceed the national average.14 And poverty rates are highest for families headed by single women, particularly if they are Black or Hispanic.14
With almost 20 percent of African Americans not having health insurance, cost is a significant factor in being able to access mental health services. 15 By including mental health assessments in primary care, there will be a reduced need for expensive specialized care; especially if the assessments are used to do early intervention, such as lifestyle changes and medications, before there is need or acute care. 15 Making mental healthcare accessible and affordable for African Americans requires coordinated efforts across healthcare systems, and advocacy and activism in the policy arena.15 Several major reasons account for high rates of depression and low rates of treatment for depression among African American women.14 A lack of adequate health care can significantly contribute to low rates of treatment among African-Americans, particularly African-American women.14 More than 20 percent of Black Americans are uninsured compared to fewer than 12 percent of Whites, according to the Department of Health Human Services.14
A report published by researchers at the University of Wisconsin-Madison found that poverty, parenting, racial and gender discrimination put Black women — particularly low- income Black women — at greater risk for major depressive disorder (MDD).14 Studies show about 72 percent of Black mothers are single, compared to 29 percent for non-Hispanic Whites, 53 percent for Hispanics, 66 percent for American Indian/Alaska native and 17 percent for Asian/Pacific Islander.14 Approximately 30% of African American households are headed by a woman with no husband present, compared with about 9% of white households.6 Since Black women are more likely to be poor, to be unmarried and to parent a child alone, which are all stressors that can contribute to poor mental health, they are also least likely to have adequate insurance.14
Solutions to the affordability issue also include options like having support groups that are both community-based and faith-based, which will also solve a lot of the accessibility and acceptability issues as well. 15
Attitudes:
Depression can affect anyone, but cultural and gender differences cause African-American women to experience depression differently.14 Attitudes and beliefs about mental illness and mental health services in the Black community tend to lean toward the idea that therapy is not a traditional coping mechanism for Blacks. 14 Researchers at the National Alliance for Mental Illness (NAMI) find that “African American women tend to reference emotions related to depression as “evil” or “acting out”.14 Avoiding emotions was a survival technique, which has now become a cultural habit for African-Americans and a significant barrier to treatment for depression.14 As a result, Black women are more likely to deal with the shame many feel about poor mental health and depression in much of the same way by avoiding the emotional toll it takes on them.14
Part of the challenge in getting care is the cultural belief that only people who are “crazy” or “weak” see mental health professionals.12 Women are so busy taking care of everyone else — their partners, their elderly parents and their children — they don’t take care of themselves.12 Women should be reminded that attending to their own needs, whether physical or emotional, doesn’t make you weak.12 It makes you better able to care for your loved ones in the long run” .12 Chisholm (1996) suggested that the “superwoman syndrome” may cause feelings of failure and frustration.13 Being a superwoman meant that mothers adapted to caring for babies, work, homes, families, husbands, and themselves without complaining of the pain or discomfort during their postpartum period.13 Depression, according to the myth, symbolizes internal weakness, lack of mental capacity, and lack of control of your senses, rather than an illness that requires medical attention.13 Having depression, of any kind, decreased respect for a person in the African-American community.13Acceptance of myths may have caused failure to seek help, not take their prescribed medication, and/or rendered them unable to recognize the signs and symptoms of depression when faced with it.13 Stereotypes such as the “Angry Black Woman” or the “Black Superwoman” are based in a reality in which black women are expected to do everything perfectly and all at once. 15 Through the ideal of the strong Black woman, African-American women are subject not only to historically rooted racist and sexist characterizations of Black women as a group but also a matrix of unrealistic interracial expectations that construct Black women as unshakable, unassailable and naturally strong. 14
Findings from the National Mental Health Association’s survey of African-American attitudes about clinical depression, suggested that African Americans fear seeking help for mental illness, feel embarrassed about seeking help, and refuse help because of denial (Mitchell, 1998).13 The practice of repressing feelings as a survival strategy continued to be an aspect of black life long after slavery ended.13 Since white supremacy and racism did not end with the Emancipation Proclamation, black folks felt it was still necessary to keep certain emotional barriers intact.13 And, in the world-view of many black people, it became a positive attribute to mask, hide, and contain feelings and came to be viewed by many black people as a sign of strong character.13 To show one’s emotions was seen as foolish.13 Traditionally, in Southern black homes, children are taught at an early age that it was important to repress feelings (hooks, 1993, p. 133).13
Despite the seemingly large challenges Black women face with regard to mental health and depression (such as racism and sexism), they have been able to develop alternative coping techniques to deal with various stressors and depression (from external society and largely through a lot of relationships and support systems that they built for themselves among relatives and among friends).14 Different types of support all contribute to the strength of social capital for each individual within a community. 19 A characteristic that defines someone’s social capital is the type and strength of their ties to other individuals (including bonding, bridging, and linking, ties with people of similar or different social characteristics, and linking ties are ties with colleagues in differing levels of hierarchies). 19 Online identities can nurture positive relationships and increase psychosocial wellbeing. There is also evidence to show that increased online involvement may serve to isolate individuals from the support they may be able to find in their geographical location.3
USPSTF:
The US Preventive Services Task Force (USPSTF) is an independent, voluntary body that makes recommendations about the effectiveness of specific preventive care services for patients without related signs or symptoms.1 The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF.1 This recommendation applies to adults 18 years and older.1 The USPSTF recommendations do not apply to children and adolescents, who are addressed in a separate USPSTF recommendation statement.1 It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance.1 The USPSTF recommends screening in all adults regardless of risk factors (general adult populations, prevalence rates vary by sex, age, race/ethnicity, education, marital status, geographic location, and employment status).1 Nevertheless, these same factors are associated with an increased risk of depression. The USPSTF also recommends that screening be implemented with adequate systems in place.1 “Adequate systems in place” refers to having systems and clinical staff to ensure that patients are screened and, if they screen positive, are appropriately diagnosed and treated with evidence-based care or referred to a setting that can provide the necessary care.1 These essential functions can be provided through a wide range of different arrangements of clinician types and settings.
In the available evidence, the lowest effective level of support consisted of a designated nurse who advised resident physicians of positive screening results and provided a protocol that facilitated referral to evidence-based behavioral treatment.1 At the highest level, support included screening; staff and clinician training (1- or 2-day workshops); clinician manuals; monthly training lectures; academic detailing; materials for clinicians, staff, and patients; an initial visit with a nurse specialist for assessment, education, and discussion of patient preferences and goals; a visit with a trained nurse specialist for follow-up assessment and ongoing support for medication adherence; a visit with a trained therapist for CBT; and a reduced copayment for patients referred for psychotherapy.1
The USPSTF concludes that there is a moderate net benefit to screening for depression in adults, including older adults, who receive care in clinical practices that have adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up after screening.1 The USPSTF also concludes that there is a moderate net benefit to screening for depression in pregnant and postpartum women who receive care in clinical practices that have CBT or other evidence-based counseling available after screening.1 They determined that programs combining depression screening with adequate support systems in place improve clinical outcomes (ie, reduction or remission of depression symptoms) in adults, including pregnant and postpartum women.1 It is important that a range of treatment options are available for pregnant and postpartum women with depression who are identified through screening and that treatment choices are made through shared decision making.1 The USPSTF revised the implementation section to clarify that a range of staff types, organizational arrangements, and settings can be used to support the goals of depression screening and provided a link to the Substance Abuse and Mental Health Services Administration registry of evidence-based mental health interventions as a resource.1 Comments suggested that access to depression screening and management resources would be useful.1
The Community Preventive Services Task Force, which makes evidence-based recommendations on improving depression symptoms, adherence to treatment, response to treatment, response to remission, recovery from depression, preventive services for community populations and recommends collaborative care for the management of depressive disorders as part of a multicomponent, health care system–level intervention that uses case managers to link primary care providers, patients, and mental health specialists.1 This collaboration is designed to improve the routine screening and diagnosis of depressive disorders, as well as the management of diagnosed depression via Multidisciplinary team–based primary care that includes self-management support and care coordination has been shown to be effective in management of depression.1 It recommends collaborative care for the treatment of major depression in adults 18 years and older on the basis of strong evidence of effectiveness in improving short-term treatment outcomes.1 As defined, collaborative care and disease management of depressive disorders include a systematic, multicomponent, and team-based approach that “strengthens and supports self-care, while assuring that effective medical, preventive, and health maintenance interventions take place” to improve the quality and outcome of patient care.1
In 2009, the USPSTF recommended screening all adults when staff-assisted depression care supports are in place and selective screening based on professional judgment and patient preferences when such support is not available.1 In recognition that such support is now much more widely available and accepted as part of mental health care, the current recommendation statement has omitted the recommendation regarding selective screening, as it no longer represents current clinical practice.1 The current statement also specifically recommends screening for depression in pregnant and postpartum women, subpopulations that were not specifically reviewed for the 2009 recommendation.1
Treatment:
A report published by the National Institute of Health (NIH) examined Black women’s representations and beliefs about mental illness.14 Researchers cite the low use of mental health services by African-American women and identify stigma as the most significant barrier to seeking mental health services among Blacks.14 African-American women have some of the lowest rates of use of depression care and experience higher rates of depression than their White female or Black male counterparts but receive lower rates of adequate treatment.14 Women are at least twice as likely to experience an episode of major depression as men and, compared to their Caucasian counterparts, African-American women are only half as likely to seek help.12 According to the Health and Human Services Office of Minority Health, African Americans are 20% more likely to experience serious mental health problems than the general population.15 And yet, only about 25 percent of African Americans seek mental health care as compared to 40 percent of whites, according to the National Alliance on Mental Illness. 15 African Americans experience more severe forms of mental health conditions due to unmet needs and other barriers.16
Depression is usually treated with medications, psychotherapy, or a combination of the two.2 Electroconvulsive therapy (ECT) and other brain stimulation therapies, antidepressants or specific psychotherapy approaches, alone or in combination are effective but aren’t the answer to preventing new cases of depression, it just solves the symptoms.1 There should be a discussion, a community where people who suffer depression can vent about their successes and failure in regards to the search of finding depression and/or support one another efforts.1 Black women are among the most undertreated groups for depression in the nation, which can have serious consequences for the African-American community.14 There is little debate among investigators that there is a shortage of research data on depression in African Americans generally, and more specifically on African American women.10 Lack of adequate and sufficient research on African Americans contributes to the problems of misdiagnoses, underdiagnoses, and undertreatment of depression in African American women.10
Holistic Treatment:
Contextualized (holistic) treatments have been reported as successful in reducing depression symptoms in African American women.10 These holistic therapies address both physical and psychological symptoms in both diagnostic and treatment modalities (Warren, 1994) .10 Clearly, more empirical studies on effective treatments for depression in African American women are needed to begin shrinking the gap in mental health disparities for African American women and to close the gap in the literature on effective depression treatments for this underserved and understudied group.10 Offering an integrated care model that includes wraparound services is important in the holistic treatment of Black psychiatry patients, many of whom find support within family, churches, and the community.5
African-Americans tend to cope with mental health problems by using informal support systems within families, communities and religious institutions, neighbors and coworkers, according to a 2010 study published in Qualitative Health Research.14 In many cases they seek treatment from ministers and physicians as opposed to mental health professionals.14 This form of coping can be beneficial for Black women who are uncomfortable with traditional forms of mental health care.14 But it can also encourage beliefs about stigma surrounding mental health in the Black church.14Mays, Caldwell, and Jackson (1996) found that religious affiliation was supportive for African-American women experiencing emotional problems.13 They suggested that those women who were connected with religious community-based resources sought fewer mental health services and that this may be an important preventive strategy for serious mental illness among African-American women.13 Researchers have found that African-American women improve greatly after using methods such as cognitive behavioral therapy, exposure therapy, and mindfulness-based stress reduction.11
Proposed Solutions:
The way we communicate, as geographical communities that usually share information via bulletin board systems and private networks that enable peer to peer communities, is being re-defined as social media and is reshaping how people self-identify, communicate, and associate within and among communities.17 The way society defines 'community' is ever-changing and subgroups of geographical communities are finding different ways to communicate with each other. Virtual communities can even substitute or complement face to face support groups completely.17 However, with more communication methods, come more opportunities to give, share and receive information (whether the information is true or false).17 Since the primary medium for virtual communities is the internet (via mailing lists, newsgroups or net discussion forums, web-based discussion forums, and live chatrooms), social support formed or facilitated in geographic communities are no longer bounded by political borders or geographic distance.17,19
Communities are essentially a unification of subgroups who share thoughts, experiences, ideas, values and certain interests. Subgroups can be compartmentalized based on demographic variables, resources utilized, and even by the different ways its constituents communicate with each other. An online support group for African American women who suffer from depression, designed by female African American health professionals can help strengthen and maintain the relationship clinician-and-patient; proving that community building (whether online or geographical) leads to effective interventions. Communities provide additional and/or adequate-enough support to its constituents and subgroups, leaving a longer lasting impression of an intervention on both geographical and virtual ones. This would require the community to be identified accurately, presented with correct information, and for the intervention to have a valid, community-wide, and reliable outcome/effect. Courses like mental health first-aid will assist communities and professionals in early detection and referral to services that will reduce mental health crises that can have negative lifelong impacts. 15 Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions, including depression.2 During clinical trials, some participants receive treatments under study that might be new drugs or new combinations of drugs, new surgical procedures or devices, or new ways to use existing treatments.2 Other participants (in the “control group”) receive a standard treatment, such as a medication already on the market, an inactive placebo medication, or no treatment.2 The goal of clinical trials is to determine if a new test or treatment works and is safe.2 Although individual participants may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.2
A qualitative approach needs to be used to examine Depression among African-American women.13 Based on Quimby’s highlighted advantages in applying qualitative and ethnographic research approaches (i.e., placing a high value on the beliefs, attitudes, and assumptions of the group under study while increasing rates of retention and compliance with protocols)10 , a qualitative approach would be deemed appropriate to examine social support from online social support groups (as a part of a nine month study) as a method of decreasing cases of Depression among African-American women.13
Recruitment and interviews can be conducted until saturation of the data occurs.13 Recruits for the online support group would be obtained from professional and personal colleagues.13 Criteria for inclusion also included being over 18 years of age, English- speaking, an African-American woman, and/or an African American woman who had had PPD during the previous 3 years.13
Pregnant and non-pregnant African American women would be incentivized to participate in an online social support group that is part of a nine month study, if they reported that they had been diagnosed as having Major Depressive Disorder, Suicidal Depression, PTSD, Post-Partum Depression or Perinatal Depression by their health care provider or by self-report of depression after childbirth.13 Participants would be screened using open-ended questionnaires based on research findings from previously mentioned studies.13
This questionnaire/screening tool would incorporate questions addressing African-American mothers’ perceived stress immediately postpartum, questions about African-American women’s perceived and received levels of family and social support, perception of being overloaded or overwhelmed, and thoughts of thoughts of harm, losing control and suicide.13Instead of filling out a simple paper form given in the waiting room, it can be done electronically before we show up for our annual visit or done on a tablet of some sort. 15 This would make the most basic of mental health care accessible and make mental health more acceptable to talk about. 15 Since the primary medium for virtual communities is the internet (via mailing lists, newsgroups or net discussion forums, web-based discussion forums, and live chatrooms), social support formed or facilitated in geographic communities are no longer bounded by political borders or geographic distance.17, 19
To address the accessibility issue, there will be a recruitment and training of Black mental healthcare providers, and training of more providers in culturally competent methodologies. 15 (It is important to note that being Black does not by default make one skilled in anti-racist practice).15 There also needs to be monitoring, advocacy and activism connected to how mental health care will fare if the Affordable Care Act gets dismantled. 15 The need to continue to advocate for expanded health insurance coverage and the provision of low-cost mental health services is more dire than ever. 15 It is important to find a provider who demonstrates cultural competence - which describes the ability of healthcare systems to provide care to patients with diverse values, beliefs and behaviors and taking into account their social, cultural and linguistic needs.16
Perceived Challenges:
Quimby also delineates the disadvantages of qualitative and ethnographic research approaches (i.e., potentially biased perceptions of researchers/interviewers who are unaware of the pitfalls of this kind of data collection e.g., generalizing from smaller select high-need populations to larger populations) with results that are spurious, thereby perpetuating inaccurate reporting of data regarding ethnic and culturally diverse groups.10
Variations in reliability and validity of diagnostic methods and procedures can be and should be addressed in controlled clinical studies and especially in studies whose populations are ethnically and culturally different from populations on which the assessment instruments were standardized.10 Many studies comprised of ethnically diverse groups fail even to discuss study limitations associated with undetermined or poor reliability and validity of methods used and applied to the groups under study (Chou, Jiann-Chyun, & Chu, 2002).10
While depression is a real illness that should be taken seriously, there is no specific diagnostic test for peripartum depression.3 To be diagnosed with peripartum depression, symptoms must begin within four weeks following delivery, however, symptoms of depression may occur at any time.3 While there is no specific diagnostic test for peripartum depression, it is a real illness that should be taken seriously.3 The optimum interval for screening for depression is unknown; more evidence for all populations is needed to identify ideal screening intervals.1 Screening must be coupled with appropriate follow-up and treatment when indicated (preparations made to initiate medical therapy, refer patients to appropriate care, or both), and systems should be in place to ensure follow-up for diagnosis and treatment.1
A study compared a computer mediated (voicemail) support group with a face to face group, noting that participation rates were significantly higher in the virtual group, but another study showed that virtual groups may be less effective than face to face groups to sustain weightloss.17 It is currently not clear whether participation in a peer to peer group reduces or increases the use of health care.17 Participants in self-help groups may be a self-selected subgroup in whom self-help processes are effective but that doesn’t mean that there isn’t involvement from other health professionals in that process.17 In certain instances, participants may have the intrinsic desire to communicate with other people, which can prove virtual communities to be not as useful.17 There are many instances, where “stand alone” peer to peer interventions had involvement from health professionals, with trained individuals leading the groups as moderators or facilitators by stimulating discussions, formulating questions, or posting topics of interest or educational material on the bulletin boards.17 However, there should still be a discussion, a community where people who suffer depression can vent about their successes and failure in regards to the search of finding depression and/or support one another efforts.1
Conclusion:
The communication accommodation theory (Giles, Coupland & Coupland, 1991) would make the most sense as the basis of an intervention designed to increase social support perceived by African American women and mothers who suffer from different forms of depression (including
Clinical depression, suicidal depression, post-partum depression, peripartum depression, untreated depression, and PTSD) because it can help us understand the formation of support networks for depressed Black women who suffer from depression, based on interpersonal factors to reshape, provide and replicate other networks of support networks for thembased on those findings.
An online support group that collaborates with other advocacy groups, research groups, state and local politicians can enforce a more intricate vetting process of this online support group, as a strategy of intervention to make mental health care accessible and make mental health more acceptable to talk about among depressed Black women. Also creating a set of policies based on positive social modeling that, would require all online support groups to set a generalizable standard of consequences to those who don’t adhere to an online community’s policy and code of conduct during the duration of their participation in that online support group would improve online social capital and garner social trust among on online communities and their intergroups.19
Enforcing standards of intricate vetting upon participants signing up for online support groups and ensuring that its participants are adhering to that code of conduct through-out the duration of their participation in that online group, can make it easier for Black women and mothers who suffer from depression to create their own identities and promote their intergroup attitudes more online communities.
Online communities have an effect on participant retention and the effectiveness of automated lifestyle interventions just like geographical communities.18 An active online community might contain user posted stories about overcoming barriers, empathic messages of support for those who are struggling, and celebrations of success18 If we can figure out how effective social support can be maximized by electronic support groups, it could leverage social support, positive social modeling, and dynamic content to keep users engaged in the program and to support behavior change.18 References:
Recommendations for Screening for Depression in Adults - JAMA. (n.d.). Retrieved from https://jamanetwork.com/journals/jama/fullarticle/2484316.
Depression Basics. (n.d.). Retrieved from https://www.nimh.nih.gov/health/publications/depression/index.shtml
(n.d.). Retrieved from https://www.apa.org/pi/women/resources/reports/postpartum-depression
International Foundation for Research and Education on Depression. (n.d.). Retrieved from https://www.ifred.org/
Best Practice Highlights African Americans/Blacks. (n.d.). Retrieved from https://www.psychiatry.org/File Library/Psychiatrists/Cultural-Competency/Treating-Diverse-Populations/Best-Practices-AfricanAmerican-Patients.pdf
(n.d.). Retrieved from https://www.apa.org/advocacy/health-disparities/health-care-reform
(n.d.). Retrieved from https://www.psychiatry.org/psychiatrists/cultural-competency/education/mental-health-facts
Abrams, J. A., Hill, A., & Maxwell, M. (2019, May). Underneath the Mask of the Strong Black Woman Schema: Disentangling Influences of Strength and Self-Silencing on Depressive Symptoms among U.S. Black Women. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/31086431
Jagannathan, M. (2018, December 18). What keeps some black women from seeking mental health care - and how therapists are working to change that. Retrieved from https://www.marketwatch.com/story/what-keeps-some-black-women-from-seeking-mental-health-care-and-how-therapists-are-working-to-change-that-2018-12-18
Carrington, C. H. (2006, July). Clinical depression in African American women: diagnoses, treatment, and research. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/16703605
Abrams, J. A., Hill, A., & Maxwell, M. (2019, May). Underneath the Mask of the Strong Black Woman Schema: Disentangling Influences of Strength and Self-Silencing on Depressive Symptoms among U.S. Black Women. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/31086431
Mental Health Among African-American Women. (n.d.). Retrieved from https://www.hopkinsmedicine.org/health/wellness-and-prevention/mental-health-among-african-american-women
(PDF) Postpartum Depression Among African-American Women. (n.d.). Retrieved from https://www.researchgate.net/publication/10867385_Postpartum_Depression_Among_African-American_Women
Hamm, N. (2018, October 8). African-American Women and Depression. Retrieved from https://psychcentral.com/lib/african-american-women-and-depression/
White, R. C. (2018, July 27). "We Need to Normalize Mental Health Care in the Black Community.". Retrieved from https://thriveglobal.com/stories/mental-health-black-community/
Facts & Statistics. (n.d.). Retrieved from https://adaa.org/about-adaa/press-room/facts-statistics
Eysenbach, G., Powell, J., Englesakis, M., Rizo, C., & Stern, A. (2004). Health related virtual communities and electronic support groups: systematic review of the effects of online peer to peer interactions. Bmj, 328(7449), 1166. doi: 10.1136/bmj.328.7449.1166
Richardson, C. R., Buis, L. R., Janney, A. W., Goodrich, D. E., Sen, A., Hess, M. L., … Piette, J. D. (2010, December 17). An online community improves adherence in an internet-mediated walking program. Part 1: results of a randomized controlled trial. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3056526/.
Cooper, S., & Palmedo, C. (n.d.). Social Media as a Transformative Force in Intercultural Health Communications: A Case Study of The Badass Army. Social Media as a Transformative Force in Intercultural Health Communications: A Case Study of The BADASS Army. Retrieved from https://bbhosted.cuny.edu/webapps/blackboard/execute/content/file?cmd=view&content_id=_43186947_1&course_id=_1762708_1&launch_in_new=true
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