Depression among older adults is a major public health concern leading to increased disability and mortality. Less than 3% of older adults utilize professional mental health services for the treatment of depression, less than any other adult age group. And despite similar rates of depression, African Americans are significantly less likely to seek, engage and be retained in professional mental health services than their white counterparts. Cultural differences in the way depression symptoms are manifested, defined, interpreted and labeled may in part explain some of these racial differences in help-seeking behaviors. Focus group methodology was utilized to identify and explore attitudes and beliefs about depression and mental health treatment utilization among 42 older African Americans who had recently suffered a major depressive episode. Thematic analysis of identified six overarching themes: (a) perceptions of depression, (b) the African American experience, (c) seeking treatment as a last resort, (d) myths about treatment, (e) stigma associated with seeking treatment and (f) culturally appropriate coping strategies. We discuss implications for practice, education and research.
Aging; Depression; Stigma; Treatment
Stigma associated with mental illness continues to be a significant barrier to help seeking, leading to negative attitudes about mental health treatment and deterring individuals who need services from seeking care. This study examined the impact of public stigma (negative attitudes held by the public) and internalized stigma (negative attitudes held by stigmatized individuals about themselves) on racial differences in treatment seeking attitudes and behaviors among older adults with depression.
Random digit dialing was utilized to identify a representative sample of 248 African American and White adults older adults (over the age of 60) with depression (symptoms assessed via the Patient Health Questionnaire-9). Telephone based surveys were conducted to assess their treatment seeking attitudes and behaviors, and the factors that impacted these behaviors.
Depressed older adult participants endorsed a high level of public stigma and were not likely to be currently engaged in, nor did they intend to seek mental health treatment. Results also suggested that African American older adults were more likely to internalize stigma and endorsed less positive attitudes toward seeking mental health treatment than their White counterparts. Multiple regression analysis indicated that internalized stigma partially mediated the relationship between race and attitudes toward treatment.
Stigma associated with having a mental illness has a negative influence on attitudes and intentions toward seeking mental health services among older adults with depression, particularly African American elders. Interventions to target internalized stigma are needed to help engage this population in psychosocial mental health treatments.
Stigma; Depression; Treatment; Aging
Little is known about African American women's beliefs about mental illness. In this qualitative study we employed the Common Sense Model (CSM) to examine African American women's beliefs about mental illness, coping behaviors, barriers to treatment seeking, and variations in beliefs, coping, and barriers associated with aging. Fifteen community-dwelling African American women participated in individual interviews. Dimensional analysis, guided by the CSM, showed that participants believed general, culturally specific, and age-related factors can cause mental illness. They believed mental illness is chronic, with negative health outcomes. Participants endorsed the use of prayer and counseling as coping strategies, but were ambivalent about the use of medications. Treatment-seeking barriers included poor access to care, stigma, and lack of awareness of mental illness. Few age differences were found in beliefs, coping behaviors, and barriers. Practice and research implications are discussed.
African Americans; coping and adaptation; dimensional analysis; mental health and illness; stigma; women's health
How racial differences influence depressed elders' seeking and obtaining treatment for depression is poorly understood. Studies in other medical illnesses show older African Americans use fewer health-care services for heart disease, stroke, and renal dialysis. This article reviews the racial composition of Duke University's Clinical Research Center (CRC) for the Study of Depression in the Elderly. Possible explanations for low participation of African Americans in such programs also are discussed. During most of the first year of the CRC project, minority enrollment varied from 5% to 10%, at least one third the African-American population of the area. Active efforts to improve minority recruitment increased this percentage to 15% by the end of the project's second year. Likely explanations for low minority participation rates include 1) elders may recognize depressive symptoms, but do not seek or cannot obtain medical treatment, and 2) depressive symptoms may be attributed to a crisis of the spirit (so help is sought through prayer and the church), the "slowing down" process of aging, or part of life's burden to be endured. Future attempts at both treatment and clinical research recruitment efforts are needed to address these possibilities.
Staff who provide support services to older adults are in a unique position to detect depression and offer a referral for mental health treatment. Yet integrating mental health screening and recommendations into aging services requires staff learn new skills to integrate mental health and overcome client barriers to accepting mental health referrals. This paper describes client rates of depression and a novel engagement intervention (Open Door) for homebound older adults who are eligible for home delivered meals and screened for depression by in-home aging service programs.
Homebound older adults receiving meal service who endorsed depressive symptoms were interviewed to assess depression severity and rates of suicidal ideation. Open Door is a brief psychosocial intervention to improve engagement in mental health treatment by collaboratively addressing the individual level barriers to care. The intervention targets stigma, misconceptions about depression, and fears about treatment, and is designed to fit within the roles and responsibilities of aging service staff.
Among 137 meal recipients who had symptoms when screened for depression as part of routine home meal service assessments, half (51%) had Major Depressive Disorder and 13% met criteria for minor depression on the SCID. Suicidal ideation was reported by 29% of the sample, with the highest rates of suicidal ideation (47%) among the subgroup of individuals with Major Depressive Disorder.
Individuals who endorse depressive symptoms during screening are likely to have clinically significant depression and need mental health treatment. The Open Door intervention offers a strategy to overcome barriers to mental health treatment engagement and to improve the odds of quality care for depression.
depression; access to care; mental health intervention; engagement
The social determinants unique to African-American men’s health contribute to limited access and utilization of health and mental health care services and can have a deleterious effect on their overall health and well-being. There is a need to examine the complex issues concerning African-American men’s help-seeking behaviors relative to mental health concerns. Current research estimates that African-American men are approximately 30% more likely to report having a mental illness compared to non-Hispanic Whites and are less likely to receive proper diagnosis and treatment. There is an extensive body of research that supports the view that women are more likely to seek help for psychological problems than African-American men. This review explores the psychosocial, environmental and socio-cultural factors that influence mental health help-seeking behavior among African-American men and explains the urgency to engage various stakeholders to pursue effective behavioral strategies. Research literature concerning the relationships between social determinants of health and their mental health help-seeking behaviors is reviewed and discussed in this paper. The article illustrates the need for mental health providers and researchers to establish feasible, culturally competent prevention and intervention strategies to increase help seeking behavior among African-American men, thereby contributing to the reduction of mental health disparities.
Social behavior; Minority health; Men’s health; Help-seeking; Mental health
Depressed mothers, especially those who are African American, are likely to underutilize mental health services. Children of depressed mothers are an at-risk population with mental health needs that are often unmet. This prospective pilot study examined 3-month frequency rates and predictors of mental health utilization for a sample of African American depressed mothers and their children.
Mothers and 1 of their children completed assessment interviews. Three months later, mothers completed a telephone interview of maternal and child mental health utilization.
Overall, 65.3% of depressed mothers and 36.7% of their children had utilized mental health services. Logistic regression analyses indicated that initial mental health treatment significantly predicted maternal mental health utilization. Maternal reports of child behavioral problems significantly predicted child mental health utilization.
The findings were consistent with other research and showed evidence of mental health use among African Americans who are in need of such services.
mental health; obstetrics/gynecology; depression; race/ethnicity; minority health
The purpose of this study was to compare the relative effectiveness of several different strategies for recruiting elderly Asians, African Americans, and Caucasians to participate in mental health research.
A total of 35 African American, 24 Asian American, and 215 Caucasian participants were phone-screened for potential enrollment into a University of California, San Francisco Department of Psychiatry treatment outcome study for older adults (60+ years of age) with major depression and mild cognitive impairment.
The methods by which participants were recruited were recorded, coded into composite categories, and statistically analyzed to determine whether certain recruitment strategies were disproportionately effective for recruiting participants from the three racial groups.
Fisher's exact test analyses revealed that Asians and African Americans were significantly less likely than Caucasians to be recruited through mental health-based methods, and African Americans were significantly more likely than Caucasians and Asians to be recruited via referrals rather than solicitations. Logistic regression, which controlled for potential confounds, largely supported these findings.
Findings suggest that the recruitment of elderly African or Asian Americans into mental health treatment outcome research can be facilitated by a flexible consumer-oriented strategy that integrates multiple recruitment methods. Establishing study credibility through non-mental health media and professional referral sources may be especially effective in engaging the participation of elderly Asian Americans; and cultivating ongoing relationships with key gatekeepers, who can observe benefits to the community, may be particularly effective in recruiting elderly African Americans.
recruitment; Asian; African American; minority; late life depression; cognitive impairment; executive dysfunction
Although racial/ethnic differences have been found in the use of mental health services for depression in the general population, research among Veterans has produced mixed results. This study examined racial/ethnic differences in the use of mental health services among 148 Operation Enduring/Iraqi Freedom (OEF/OIF) Veterans with high levels of depression and posttraumatic stress disorder (PTSD) symptoms and evaluated whether religious coping affected service use. No differences between African American, Hispanic, and Non-Hispanic white Veterans were found in use of secular mental health services or religious counseling. Women Veterans were more likely than men to seek secular treatment. After controlling for PTSD symptoms, depression symptom level was a significant predictor of psychotherapy attendance but not medication treatment. African American Veterans reported higher levels of religious coping than whites. Religious coping was associated with participation in religious counseling, but not secular mental health services.
We examined African American women's representations/beliefs about mental illness, preferred coping behaviors if faced with mental illness, whether perceived stigma was associated with treatment-seeking, and if so, whether it was related to beliefs and coping preference, and whether these variables differed by age group. Participants were 185 community-dwelling African American women 25 to 85 years of age. Results indicated the women believed that mental illness is caused by several factors, including family-related stress and social stress due to racism, is cyclical, and has serious consequences but can be controlled by treatment. Participants endorsed low perceptions of stigma. Major preferred coping strategies included praying and seeking medical and mental health care. Age differences were found in all variables except stigma.
African American women; beliefs about mental illness; attitudes about mental illness; stigma; coping behaviors
The current study aims to further our understanding of the applicability of the transtheoretical model (TM) to intimate partner violence (IPV), with particular focus on mental health symptoms (depression, posttraumatic stress disorder symptomatology, suicidal ideation) in a sample of low-income African American women seeking medical services at an inner city emergency department. Results revealed that of the 121 abused African American women, the majority (95%) were in the precontempla-tion and contemplation stages of the change process. Further, contrary to predictions, bivariate analyses revealed those at further stages of change endorsed more severe mental health symptoms. However, a multivariate analysis of variance examining differences in level of mental health symptoms between women high and low on stages of change was inconclusive due to the small number of women at the higher stages of the TM model. These findings contribute to the growing body of literature supporting the TM as applied to IPV. Results are discussed in terms of applicability to intervention design.
intimate partner violence; African American women; transtheoretical model
The purpose of this study is to better understand the mental health/illness information and service delivery preferences among African American residents of Baltimore. We conducted four focus groups (n=42) among African American adults currently unconnected with the mental health system. Participants expressed fear of stigma and perceptions of racism as major barriers to seeking information and/or services and discussed some normalizing strategies to address these barriers. African Americans harbor cultural and traditional beliefs regarding mental illness which could also act as barriers. Findings have implications for imparting acceptable and culturally-sensitive mental health education and service delivery programs in community settings.
mental health; minority health; help-seeking; stigma; health information; qualitative research
African American women are at high risk for sexual assault. In addition, many African American women endorse use of social support and religiosity to cope with life stressors. The current study investigates the relationship between these two coping strategies and post-trauma symptoms (depression and PTSD) in a sample of 413 African American female sexual assault survivors using confirmatory factor analysis and structural equation modeling. Findings indicated that African American assault survivors who have greater social support were less likely to endorse symptoms of depression and PTSD. Conversely, increased use of religious coping was related to greater endorsement of depression and PTSD symptoms. Counseling and research implications are explored.
Background and Objectives
Older African Americans are often under diagnosed and under treated for depression. Given that older African Americans are more likely than whites to identify spirituality as important in depression care, we sought to understand how spirituality may play a role in the way they conceptualize and deal with depression in order to inform possible interventions aimed at improving the acceptability and effectiveness of depression treatment.
Cross-sectional qualitative interview study of older African American primary care patients.
Participants and Setting
Forty-seven older African American patients recruited from primary care practices in the Baltimore, MD area, interviewed in their homes.
Semi-structured interviews lasting approximately 60 minutes. Interviews were transcribed and themes related to spirituality in the context of discussing depression were identified using a grounded-theory approach.
Participants in this study held a faith-based explanatory model of depression with a particular emphasis on the cause of depression and what to do about it. Specifically, participants described depression as being due to a “loss of faith” and faith and spiritual/religious activities were thought to be empowering in the way they can work together with medical treatments to provide the strength for healing to occur.
The older African Americans in this study described an intrinsically spiritual explanatory model of depression. Addressing spirituality in the clinical encounter may lead to improved detection of depression and treatments that are more congruent with patient’s beliefs and values.
depression; geriatrics; ethnicity; religiosity; spirituality
Whites in community samples utilize mental health services at a much higher rate than African Americans (Kessler, et al., 2005). Is this also the case among those in jails? In this study of jail inmates (229 African American, 185 White) there were no race difference in the overall need for mental health treatment (63% of participants had significant symptoms on the Personality Assessment Inventory) but race differences in the level and types of symptoms were evident. Additionally, while Whites were more likely to report pre-incarceration treatment there were no differences in treatment seeking or access to mental health programs while in jail, implying that if barriers to treatment in the community were removed (cost/insurance, location/transportation, time) racial disparities in treatment utilization may be reduced.
Mental illness; African American; Race; Treatment; Incarceration
African American adolescent boys underutilize mental health service due to stigma associated with depression. Gaining an increased understanding of how depressed, African American adolescent boys perceive their mental health needs and engage in help-seeking behaviors might play an essential role in efforts to improve their symptoms and access to care. Using a mixed-methods design, this study examined the influence of mental health stigma and social support on depressive symptoms among African American adolescent boys. Findings indicated the protective effects of social support in decreasing depressive symptoms, especially when participants experienced mental health stigma. Results also revealed the pivotal role of family social support over both professional and peer support for participants who struggled with depressive symptoms. The primacy of family support among the sample, combined with the frequent distrust of professionals and peer networks, would indicate that working with families may improve initial identification of depression among African American adolescent boys and decrease their barriers to care.
help seeking; stigma; social support; depression; African American adolescent boys
Qualitative research methods were used to understand the experiences of families seeking treatment for young people with recent-onset psychosis; such knowledge can inform services design.
The authors conducted open-ended interviews in 1999 through 2002 with family members of 13 patients with recent-onset nonaffective psychotic disorders in the New York metropolitan area, focusing on their experience in seeking treatment and engaging with mental health services.
Family members described early lack of clarity of diagnosis and obstacles to obtaining treatment. Entry into the mental health system frequently occurred in the context of crisis, with African-American families specifically reporting police involvement. Inpatient hospitalization was depicted as traumatic yet offering relief. Aftercare was described as fragmented, and issues with third-party payers were paramount. Families expressed a desire for more education, information, and support and described their struggles with stigma. These data from families are presented in the context of more recent literature as to the efficacy of specialized treatment programs for early stages of psychotic disorder and their involvement of families.
These qualitative research data support the importance of involving and educating families about psychosis: its recognition, its treatment, and access to services. They also highlight the need to address stigma and implement structural changes in treatment that ensure continuity and coverage of care. Specialized first-episode psychosis services may address these issues, and they may minimize the traumatic experiences of involuntary hospitalization and police involvement early in treatment.
Contrary to the “model minority” myth, growing research indicates that the rates of mental health problems among Asian Americans may be higher than initially assumed. This study seeks to add to the scant knowledge regarding the mental health of Asian American men by examining the role of masculine norms, coping and cultural values in predicting depression among this population (N=149). Results reveal that Asian American men who used avoidant coping strategies and endorsed the masculine norm Dominance reported higher levels of depressive symptoms. In contrast, endorsing Winning masculine norms was associated to lower levels of depressive symptoms. Findings suggest that adherence to masculine norms and avoidant coping strategies play a salient role in the mental health of Asian American men.
Asian American men; masculine norms; depression; avoidant coping; Asian values
Type 2 diabetes constitutes a leading and increasing cause of morbidity and mortality among older adults, particularly African Americans, Native Americans, Mexican Americans, and rural dwellers. To understand diabetes self-care, an essential determinant of diabetic and overall health outcomes, 80 middle aged and older adults from these four disproportionately affected racial/ethnic/residential groups engaged in in-depth interviews, focusing on approaches to and explanations for diabetes self-care. Certain self-care activities (medication-taking, diet, foot care) were performed regularly while others (blood glucose monitoring, exercise) were practiced less frequently. Despite research suggestions to the contrary, only one in four elders used unconventional diabetes therapies, and only one-third listed someone other than a health care provider as a primary information source. Few self-care differences emerged according to race/ethnicity/residence, perhaps because of the influential and common circumstance of low income. Thematic analyses suggest that inadequate resources, perceived efficacy of medication, great respect for biomedical authority, and lack of familiarity with and concerns about unconventional therapies are influential in establishing these patterns of self-care. We discuss the similarity of self-care practices and perspectives irrespective of race/ethnicity/residence and the predominance of biomedical acceptability.
Type 2 diabetes; African Americans; Mexican Americans; Native Americans; Rural residents; Self-care
This analysis examines the associations of oral health with social integration among ethnically diverse (African American, American Indian, white) rural older adults. Data are from a cross-sectional survey of 635 randomly selected community-dwelling adults aged 60+. Measures include self-rated oral health, number of teeth, number of oral health problems, social engagement, and social network size. Minority elders have poorer oral health than do white older adults. Most rural elders have substantial social engagement and social networks. Better oral health (greater number of teeth) is directly associated with social engagement, while the relationship of oral health to social network size is complex. The association of oral health with social engagement does not differ by ethnicity. Poorer oral health is associated with less social integration among African American, American Indian and white elders. More research on the ways oral health affects the lives of older adults is warranted.
Oral health disparities; social engagement; social network; rural aging
In the EHDIC-SWB study, African-Americans are less likely to have depression than non-Hispanic whites. Religious service attendance is one possible explanation because studies have shown an inverse relationship between religious service attendance and depression. We examined the relationship between race, religious service attendance, and depression in 835 African-American and 573 non-Hispanic white adults aged 18 and older in the Exploring Health Disparities in Integrated Communities-Southwest Baltimore (EHDIC-SWB) study. Religious service attendance was measured according to participants’ response to “how often do you attend religious services?” Depression was measured using the Patient Health Questionnaire. African-Americans attended religious services more frequently than non-Hispanic whites, and had a lower percentage of depression (10.1% vs. 15.4%; p-value <0.05). After adjusting for the demographic variables and health-related characteristics, African-Americans displayed lower odds of having depression (OR = 0.68, 95% CI: 0.47–0.97) compared to non-Hispanic whites. However, when including religious service attendance in the model, we found race differences in depression (OR = 0.76, 95% CI: 0.52–1.11) were no longer significant. We concluded that among individuals living in a low-income, integrated urban environment, race disparities in depression were eliminated after accounting for race differences in religious service attendance. This suggests religious service attendance may serve as a protective factor against depression for African-Americans.
Religious service attendance; Race; Depression
Family violence among older women encompasses intimate partner violence (IPV) and elder maltreatment, both linked to poor health status. Little is known about the association between family violence and the health status of older innercity African American women.
One hundred fifty-eight African American women, aged ≥50, were interviewed in the ambulatory clinics of a large public hospital. Lifetime family violence exposure as an adult was measured by the Family Violence against Older Women (FVOW) scale; physical and mental health status were measured by the physical and mental component summary scores of the Short Form 8® scale.
Mean participant age was 61.5 years (SD 7.1). Participants with FVOW scores in the top quartile were considered to have high lifetime family violence exposure. Participants with higher family violence exposure and those younger, unemployed, or disabled reported worse physical and mental health status. Lower income and not having Medicare were associated with worse physical and mental health status, respectively. Using stepwise linear regression techniques, only employment status and high family violence exposure were associated with worse physical (F = 7.16, p = 0.0011) and mental health (f = 7.09, p = 0.0012) status. Women with high FVOW scores reported physical and mental component summary scores that were 4.18 and 4.6 points lower, respectively, than those of women with lower FVOW scores.
Among older, innercity, African American women, lack of employment and high levels of family violence exposure as an adult are associated with worse physical and mental health status. Clinicians caring for older African American women need to be cognizant of the role both current and prior violence exposure may play in their patients' current health status.
To assess disparities in mental health treatment in New York City (NYC) after the World Trade Center Disaster (WTCD) reported previously related to care access, we conducted analyses among a cross-sectional survey of adults who had posttraumatic stress disorder (PTSD) or major depression (N = 473) one year after the event. The dependent variables examined were use of mental health services, in general, and use of mental health services related to the WTCD. Similar dependent variables were developed for medication usage. Although a number of bivariate results were statistically significant for postdisaster mental health visits, in a multivariate logistic regression model, only WTCD exposure remained significant. For service utilization related to the WTCD, the multivariate results indicated that African Americans were less likely to have had these visits compared to Whites, while those with a regular doctor, who had greater exposure to WTCD events, and those who had a perievent panic attack were more likely to have had such visits. In terms of medication use, multivariate results suggested that African Americans were less likely to use postdisaster medications, whereas persons 45 + years old and those with a regular doctor, were more likely to use them. For WTCD-related medication use, multivariate models indicated that African Americans were less likely to use medications, relative to Whites, while those between 45 and 64 years old, those with a regular doctor, those exposed to more WTCD events, and those who had a perievent panic attack, were more likely to have taken medications related to the disaster. The primary reason respondents gave for not seeking treatment (55% of subsample) was that they did not believe that they had a problem (73%). Other reasons were that they wanted to solve the problem on their own (5%), had problems accessing services (6%), had financial problems (4%), or had a fear of treatment (4%). Despite the availability of free mental health services offered in a supportive and potentially less stigmatizing environment post disaster, there still appeared to be barriers to receiving postdisaster services among those presumably in need of care.
Despite the large number of adolescents and young adults in employment training programs, a population that has poorer health and greater health risk than similarly aged in-school peers, we are unaware of any health interventions that have been evaluated in this setting. The primary objective of our study was to evaluate changes in depressive symptoms, coping strategies, and receipt of mental health services among low-income African American adolescents and young adults receiving a mental health intervention integrated into an employment training program.
The intervention consisted of an on-site mental health clinician, a peer-led depression prevention intervention, and training sessions for employment training staff. A pretest-posttest design assessed depressive symptoms, coping strategies, and receipt of mental health services at baseline and 12-month follow-up. Complete baseline and follow-up data were available for 136 of 218 eligible participants. Most study participants were African American (98%); average age was 18.8 years.
The intervention had no effect on depressive symptoms or coping strategies. The percentage of participants who used mental health services at follow-up increased, but not significantly. Age was associated with use of active and support-seeking coping strategies, whereas use of mental health services before program enrollment was associated with use of mental health services at follow-up.
Alternative intervention strategies may be needed to decrease the severity of depressive symptoms and increase use of coping strategies among adolescents and young adults in employment training programs. Future research evaluating such interventions should use quasi-experimental or experimental designs to provide evidence of intervention effect.
Although depression is one of the most common problems among adults in primary care settings, many do not seek or adhere to the treatment regimens suggested by their providers. Understanding the cultural model surrounding depression and its treatment in older adults might provide insight into the development of more effective strategies for addressing the problem in the clinical setting. In this study, the authors conducted semistructured interviews with adults over age 65. Personal responsibility for the management of depression emerged as a pervasive approach to dealing with depression. Older adults used orientational and movement metaphors to describe the process of moving out of depression. They viewed initiation and follow-through of this process as the sole responsibility of the depressed individual. This attitude might be rooted in the cultural experiences of this particular cohort of older adults and has implications for their use of physical and mental health services for depression.
depression; aged; cultural models