Why Race Matters If You Have Major Depressive Disorder
Millions in the United States have major depression, but the difficulty overcoming it can be higher for people of color, research shows.
Depression, also known as major depressive disorder (MDD),?is the leading cause of illness and disability worldwide, per the?World Health Organization (WHO). And while depression can affect anyone, a growing body of research shows people of color in the United States are often hit hardest by this condition.
Marginalized racial and ethnic communities, such as Black and Hispanic Americans, are more apt to experience severe and debilitating symptoms of major depression and are less apt to receive beneficial treatments, according to a May 2022 report from the?Blue Cross Blue Shield Association, a federation of American health insurance companies.
Without treatment, depression often worsens, increasing the risk for other serious health issues like?chronic pain, substance abuse, self-harm, or suicide, warn experts at?Mayo Clinic in Rochester, Minnesota.
The causes and contributors of these unfair and preventable differences in the burdens of depression and other mental health conditions are multifaceted and deep rooted. As a result, solutions aren’t straightforward. “It’s sort of like any other disparity that we see — the adage that when white America catches a cold, all the other groups get the flu,” says?Wizdom Powell, PhD, MPH, chief social impact and diversity officer at Headspace Health, and director of the Health Disparities Institute at UConn Health in Farmington, Connecticut.
Here’s what researchers know about race-related disparities in the diagnosis and treatment of MDD, as well as some potential steps that could lessen these disparities.
Why Are Marginalized Racial and Ethnic Groups Less Likely to Be Diagnosed and Treated for Depression?
Studies of depression risk among people of color have had somewhat mixed results, likely due to a lack of high-quality studies including people of color, underreported cases of depression among people of color, and widespread misdiagnoses, according to a?review article published in the journal Frontiers.
Some studies show that depression and other mental health conditions happen in Black and African American people at about the same rate or less often than in white people, say experts at?Mental Health America. Similarly, Hispanic and Latino people appear to have the same risk of developing depression and other mental health conditions as the general population, reports the?National Alliance on Mental Illness (NAMI).
But other research, such as a large study published in May 2018 in the journal?Preventive Medicine, found that African American and Latino people were more likely than white people to have depression.
While the exact relationship among race, ethnicity, and depression rates isn’t fully understood, what is known is that when people belonging to racial and ethnic minority groups develop depression, they tend to report more serious symptoms. For instance, although people of color are less likely to experience acute episodes of major depression than white Americans, they’re more likely to have chronic, prolonged, and severely debilitating depression that affects their ability to function, according to a?paper published in February 2019 in Neuropsychiatric Disease and Treatment.
Similarly, a study published in the journal Archives of Psychiatry showed that when MDD affects African American and Caribbean Black people, it’s usually more severe and disabling for them compared with non-Hispanic white people.
“What this means is the burden of disability from depression is much more pronounced in individuals from Black, indigenous, and communities of color,” Dr. Powell explains. “And the consequences of these mental health conditions are far more significant and negative for these populations.”
Despite these statistics, only 1 in 3 Black adults with a mental health condition receives treatment, say?NAMI experts. And according to the same study published in Archives of Psychiatry, only 45 percent of African American people and 24.3 percent of Caribbean Black people who met the criteria for depression received any type of treatment. Likewise, more than half of young Hispanic-Latino people ages 18 to 25 who have serious mental health conditions like depression don’t receive treatment, according to NAMI.
Black people are also more likely to seek help from emergency rooms or primary care doctors rather than mental health specialists, who are better trained to treat conditions like depression, NAMI reports.
When people in Black and Hispanic communities do receive treatment for major depression, they’re less likely to get counseling or medication, the aforementioned May 2022 Blue Cross Blue Shield Association report found.
Left untreated or insufficiently treated, depression can worsen, increasing the risk of more severe and persistent mental health issues, as well as suicide. Troublingly, suicide was the second leading cause of death among Black and African American people ages 15 to 24, per the U.S. Department of Health and Human Services Office of Minority Health. And from 1991 to 2017, African American high school students experienced a?3 percent increased rate in suicide attempts, whereas the suicide attempt rate decreased among white youths during the same time period, a study published in November 2019 in the journal Pediatrics found.
What Factors Drive These Disparities?
A combination of factors likely cause these disparities, Powell says. “We don’t have a clear connection between race and depression that we can determine under a microscope, like a biological link,” she explains.
Instead, various exposures, experiences, and accessibility issues appear to contribute to the inequalities in diagnosis and care. Also known as “social determinants of health,” these factors have a significant impact on health and well-being, according to the U.S. Department of Health and Human Services.
Historical Mistrust in Health Systems and Unequal Care Play a Role
People of color have historically been mistreated by healthcare systems in the United States. One well-known example is the?U.S. Public Health Service (USPHS) Syphilis Study at Tuskegee, in which nearly 400 African American men who had syphilis were intentionally denied treatment. Experiences like these have created mistrust among people of color toward the U.S. medical system, lessening the likelihood of many to seek care.
Some research shows that Black people today continue to encounter more negative experiences when they seek mental health treatment compared with white people. For instance, a study published in December 2018 in the journal Psychiatric Services found African American people were more apt to receive a misdiagnosis of schizophrenia than white people when they reported symptoms of mood disorders like depression. In contrast, non-Latino white people were more likely to be diagnosed with major depression.
Shortage of Mental Health Experts of Color Is Another Barrier
A?study published in November 2020 in the journal JAMA Network Open found that patients who shared the same racial or ethnic backgrounds as their doctors were more likely to report a better care experience than those who did not. However, there’s a shortage of racially-diverse mental health care providers in the United States — another possible reason people in marginalized racial and ethnic communities don’t seek treatment for depression.
“In the field of psychology, about 85 percent to 90 percent of psychologists identify as white,” says?Erlanger A. Turner, PhD, an associate professor of psychology at Pepperdine University in Malibu, California, and the author of?Mental Health Among African Americans: Innovations in Research and Practice. “If someone prefers to work with someone from their own racial background, it may be difficult to locate a mental health professional in their community.”
Language or cultural barriers between doctors and patients of different ethnicities may also be a factor. A 2022?Pew Research Center survey found that 44 percent of Hispanic people felt communication problems related to language or cultural differences were major reasons they have worse health-related outcomes than other adults in the United States.
Stress and Trauma Caused by Racism Increases the Risk of Depression
A review of nearly 300 studies,?published in PLoS One, found a significant association between racism and mental health issues like depression among people of color.
People of color often experience forms of stress from racism and inequality that white people do not experience — and stress is a strong predictor of depression, according to research published in PLoS One.
“The kind of stress that plagues the lives of people who occupy more marginalized social positions are stresses that are associated with being discriminated against, and we know that these kinds of stressors are notably different and separate these groups from non-Hispanic white people in our society,” says Powell.
Cultural Stigma Related to Mental Health Reduces Outreach
Although stigmas — negative beliefs or attitudes toward someone based on a notable characteristic like mental health issues — are common among many communities, they may be particularly pronounced in Black and African American communities. A study published in?Nursing Research found that many African American adults view mental health disorders, especially depression, as a sign of weakness. That stigma and related ones can deter people of color from seeking treatment.
Stigma toward mental health is common in Hispanic and Latino communities, too. According to?NAMI, many people within these communities consider talking about mental health challenges to be taboo.
Financial Instability Is Both a Cause and a Deterrent
In the United States, Black and Hispanic people are more likely to live below the poverty line than white people, with 19.5 percent of Black people and 17 percent of Hispanic people experiencing poverty in 2020 compared with 8.2 percent of white people, according to Statista, a provider of market and consumer data.
Financial instability is both a predictor of serious mental health issues and a significant barrier to treatment. According to?NAMI, Black adults who live below the poverty line are more than twice as likely to report serious psychological distress compared with those in more secure financial situations.
However, people affected by poverty are the least likely to be able to access mental health care, per a?review article published in January 2017 in Pediatrics.
“Despite our best efforts, we still have significant income and wealth inequalities in our nation,” explains Powell. “This type of financial strain can create a real challenge for people in terms of prioritization. There are a lot of trade-offs that people who occupy lower socioeconomic positions make around their mental health, which exacerbate these disparities.”
Lower Rates of Health Insurance Reduce Access to Care
Hispanic people and African American people have lower rates of insurance coverage and less access to health services, which contributes to inequalities in care, according to The Commonwealth Fund, an organization that aims to improve health equity in the United States and other countries.
Potential Solutions: Where Do We Go From Here?
Although the solutions for solving racial disparities in mental health care aren’t simple and will likely take time, experts have pinpointed some focused strategies and efforts that may improve the situation sooner rather than later.
Telemedicine can be used to increase access to mental health treatment. “In many states, therapists can do therapy online, which makes it more accessible for people who may have difficulties with transportation or who may not have access to a therapist in their city, but can find someone within their state,” Dr. Turner says. In addition, telemedicine may, in some cases, be more affordable than traditional in-person care.
Online platforms that offer virtual mental health counseling include:
- Ayana Therapy, a platform specifically for marginalized and intersectional communities
It’s important to meet people in marginalized communities where they are when it comes to mental health care, notes?Sidney Hankerson, MD, an associate professor and vice chair of the department of psychiatry, and the director of mental health equity research at the Institute for Health Equity Research at the Icahn School of Medicine at Mount Sinai in New York City.
“One way I am doing this is to partner with Black churches, barbershops, and other trusted settings to screen people for depression and connect them to care,” he explains. “This strategy, if it proves successful, could go a long way to reach Black Americans who would otherwise not engage in traditional mental health services.”
Powell, too, sees this type of approach as a promising way to take mental health care into marginalized communities, instead of waiting for patients to reach out on their own.
“We’re going to have to reimagine what an inclusive mental health system can look like,” she says. One example is the mental health care system in Rwanda, Africa, which Powell says has only two psychiatrists throughout the entire country.
“They are doing less with more,” Powell explains. “They are using the full range of human potential where they are training community health workers and lay health people to do mental health screenings, triage, and referrals, and that’s what we need. We need bridge builders, and to me, these bridge builders are right in our communities.”
In addition, an effective model can’t ignore the environmental conditions among people of color, Powell says.
“You’ve got to address the features in the environment that are depressionogenic. You’ve got to address poverty. You’ve got to address community violence. You’ve got to address racism, as hard as it is for us to say it out loud,” she adds.
How to Get the Help You Need Right Now
While research shows issues surrounding mental health disparities are multidimensional and challenging to overcome, they’re problems that must be addressed.
“What’s on the other side of this, is radical healing for everyone, not just people of color,” she explains. “When you raise the mental health and wellbeing of those who are the least advantaged, you raise the health and well-being for everyone.”
If you’re a part of a marginalized community and you’re struggling with depression, there are ways to boost your odds of receiving appropriate care.
Finding the right therapist for your specific needs often begins with asking questions. “It's okay to ask questions about their experience working with individuals from your community,” Erlanger says. “For example, I encourage people to ask therapists, ‘How many clients have you worked with that identify as Black or African American?’ This can help potential clients get an idea about a therapist's level of experience with understanding depression within certain groups.”?
If you’d prefer to see a therapist who isn’t in your care network, Erlanger suggests calling your insurance company to request a single-case agreement to see if your insurance provider would agree to cover the cost.
Some online directories that could help you find a therapist who works with specific marginalized racial and ethnic communities are:
- Melanin and Mental Health