Strong, Black and Female: African American Women and Depression

A couple of weeks ago, I received an email from a colleague encouraging me to read a paper she had published on the need for culturally competent treatment of depression in African American women.  As I read it, I recognized the African American women in my clinical practice for whom I have had the privilege of providing care for more than 20 years.  I have always admired their strength in the face of adversity and discrimination, their role as the central figure in their families, their spirituality – and I have developed a deep respect and fondness for them as they have shared their joys and struggles.  But it also made me question whether I have provided adequate, culturally sensitive mental and emotional support.

What I learned is that clinical depression among African American women is 50% greater than among Caucasians.  These women experience significantly more racism, sexism and poverty compared to their white counterparts, and have fewer support systems.  Many have less education, higher unemployment, work low-status, low-paying jobs, and live in sub-standard housing in high crime communities.  Subject to high levels of stress, they suffer poorer mental and physical health and low self-esteem.  And yet, they appear to be towers of strength.  Why is this so?   

Historically, African American women have suppressed emotion, masked difficulties, and maintained a code of silence. This Strong Black Woman identity and superwoman mentality of needing to be self-reliant, invulnerable, selfless, resilient, and psychologically, physically and emotional strong has been passed down generation to generation and dates back to their coping mechanisms in dealing with slavery and oppression.  Unfortunately, this may also prevent them from reaching out for needed support.  Instead, their coping mechanisms may include overeating, smoking, and alcohol and drug abuse.

Culturally in the African American community, there is a stigma associated with seeking mental and emotional health.  Treatment is considered a sign of weakness.  In addition, African American women often present to healthcare providers well-groomed and deny feeling depressed because they don’t want to be seen as not spiritually strong or lacking self-control.  Their depression often manifests as somatic complaints of GI distress, chronic pain, palpitations, dizziness, fatigue or sleep disturbances which are more socially acceptable than sadness, depression or difficulty concentrating.  They enter treatment at a later, more advanced stage and are often misdiagnosed and undertreated.  They not only have poorer access to care, but also are less likely to be prescribed and/or fill prescriptions for antidepressants or receive non-pharmacologic treatment.  Faced with seeking care from a healthcare professional who is most often European American and who lacks familiarity with the language and behavioral mannerisms of African American culture, it is not surprising that support is preferentially sought through social networks and from African American community or religious leaders.

So, what can be done to address these disparities and provide more effective, culturally sensitive care for African American women?  My colleague suggests a holistic approach that takes into consideration biopsychosocial-spiritual components including environmental, socioeconomic, health and cultural factors.  As healthcare providers, if we are cognizant of and sensitive to the Strong Black Woman Archetype and the importance of spirituality and the faith-based community, we will be better at gaining the trust of our patients and addressing their mental health needs.

Judith Wolf, MD    Associate Director, WHEP

Bernice Roberts Kennedy, PhD, PMN-CNS, BC and Chalice Jenkins, PhD, LPC, NCC 

African American Women and Depression: Promoting the Need for Culturally Competent Treatment
BRK Global Healthcare Journal, 2018, 978-1-5323-4858-7