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1.  Mental Health Treatment Seeking Among Older Adults with Depression: The Impact of Stigma and Race 
Objective
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.
Method
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.
Results
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.
Conclusion
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.
doi:10.1097/JGP.0b013e3181cc0366
PMCID: PMC2875324  PMID: 20220602
Stigma; Depression; Treatment; Aging
2.  Attitudes and beliefs about mental health among African American older adults suffering from depression 
Journal of aging studies  2010;24(4):266-277.
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.
doi:10.1016/j.jaging.2010.05.007
PMCID: PMC3060786  PMID: 21423819
Aging; Depression; Stigma; Treatment
3.  Reinterpreting Ethnic Patterns among White and African American Men Who Inject Heroin: A Social Science of Medicine Approach 
PLoS Medicine  2006;3(10):e452.
Background
Street-based heroin injectors represent an especially vulnerable population group subject to negative health outcomes and social stigma. Effective clinical treatment and public health intervention for this population requires an understanding of their cultural environment and experiences. Social science theory and methods offer tools to understand the reasons for economic and ethnic disparities that cause individual suffering and stress at the institutional level.
Methods and Findings
We used a cross-methodological approach that incorporated quantitative, clinical, and ethnographic data collected by two contemporaneous long-term San Francisco studies, one epidemiological and one ethnographic, to explore the impact of ethnicity on street-based heroin-injecting men 45 years of age or older who were self-identified as either African American or white. We triangulated our ethnographic findings by statistically examining 14 relevant epidemiological variables stratified by median age and ethnicity. We observed significant differences in social practices between self-identified African Americans and whites in our ethnographic social network sample with respect to patterns of (1) drug consumption; (2) income generation; (3) social and institutional relationships; and (4) personal health and hygiene. African Americans and whites tended to experience different structural relationships to their shared condition of addiction and poverty. Specifically, this generation of San Francisco injectors grew up as the children of poor rural to urban immigrants in an era (the late 1960s through 1970s) when industrial jobs disappeared and heroin became fashionable. This was also when violent segregated inner city youth gangs proliferated and the federal government initiated its “War on Drugs.” African Americans had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families. Most of the whites were expelled from their families when they began engaging in drug-related crime. These historical-structural conditions generated distinct presentations of self. Whites styled themselves as outcasts, defeated by addiction. They professed to be injecting heroin to stave off “dopesickness” rather than to seek pleasure. African Americans, in contrast, cast their physical addiction as an oppositional pursuit of autonomy and pleasure. They considered themselves to be professional outlaws and rejected any appearance of abjection. Many, but not all, of these ethnographic findings were corroborated by our epidemiological data, highlighting the variability of behaviors within ethnic categories.
Conclusions
Bringing quantitative and qualitative methodologies and perspectives into a collaborative dialog among cross-disciplinary researchers highlights the fact that clinical practice must go beyond simple racial or cultural categories. A clinical social science approach provides insights into how sociocultural processes are mediated by historically rooted and institutionally enforced power relations. Recognizing the logical underpinnings of ethnically specific behavioral patterns of street-based injectors is the foundation for cultural competence and for successful clinical relationships. It reduces the risk of suboptimal medical care for an exceptionally vulnerable and challenging patient population. Social science approaches can also help explain larger-scale patterns of health disparities; inform new approaches to structural and institutional-level public health initiatives; and enable clinicians to take more leadership in changing public policies that have negative health consequences.
Bourgois and colleagues found that the African American and white men in their study had a different pattern of drug use and risk behaviors, adopted different strategies for survival, and had different personal histories.
Editors' Summary
Background.
There are stark differences in the health of different ethnic groups in America. For example, the life expectancy for white men is 75.4 years, but it is only 69.2 years for African-American men. The reasons behind these disparities are unclear, though there are several possible explanations. Perhaps, for example, different ethnic groups are treated differently by health professionals (with some groups receiving poorer quality health care). Or maybe the health disparities are due to differences across ethnic groups in income level (we know that richer people are healthier). These disparities are likely to persist unless we gain a better understanding of how they arise.
Why Was This Study Done?
The researchers wanted to study the health of a very vulnerable community of people: heroin users living on the streets in the San Francisco Bay Area. The health status of this community is extremely poor, and its members are highly stigmatized—including by health professionals themselves. The researchers wanted to know whether African American men and white men who live on the streets have a different pattern of drug use, whether they adopt varying strategies for survival, and whether they have different personal histories. Knowledge of such differences would help the health community to provide more tailored and culturally appropriate interventions. Physicians, nurses, and social workers often treat street-based drug users, especially in emergency rooms and free clinics. These health professionals regularly report that their interactions with street-based drug users are frustrating and confrontational. The researchers hoped that their study would help these professionals to have a better understanding of the cultural backgrounds and motivations of their drug-using patients.
What Did the Researchers Do and Find?
Over the course of six years, the researchers directly observed about 70 men living on the streets who injected heroin as they went about their usual lives (this type of research is called “participant observation”). The researchers specifically looked to see whether there were differences between the white and African American men. All the men gave their consent to be studied in this way and to be photographed. The researchers also studied a database of interviews with almost 7,000 injection drug users conducted over five years, drawing out the data on differences between white and African men. The researchers found that the white men were more likely to supplement their heroin use with inexpensive fortified wine, while African American men were more likely to supplement heroin with crack. Most of the white men were expelled from their families when they began engaging in drug-related crime, and these men tended to consider themselves as destitute outcasts. African American men had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families, and these men tended to consider themselves as professional outlaws. The white men persevered less in attempting to find a vein in which to inject heroin, and so were more likely to inject the drug directly under the skin—this meant that they were more likely to suffer from skin abscesses. The white men generated most of their income from panhandling (begging for money), while the African American men generated most of their income through petty crime and/or through offering services such as washing car windows at gas stations.
What Do These Findings Mean?
Among street-based heroin users, there are important differences between white men and African American men in the type of drugs used, the method of drug use, their social backgrounds, the way in which they identify themselves, and the health risks that they take. By understanding these differences, health professionals should be better placed to provide tailored and appropriate care when these men present to clinics and emergency rooms. As the researchers say, “understanding of different ethnic populations of drug injectors may reduce difficult clinical interactions and resultant physician frustration while improving patient access and adherence to care.” One limitation of this study is that the researchers studied one specific community in one particular area of the US—so we should not assume that their findings would apply to street-based heroin users elsewhere.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030452.
The US Centers for Disease Control (CDC) has a web page on HIV prevention among injection drug users
The World Health Organization has collected documents on reducing the risk of HIV in injection drug users and on harm reduction approaches
The International Harm Reduction Association has information relevant to a global audience on reducing drug-related harm among individuals and communities
US-focused information on harm reduction is available via the websites of the Harm Reduction Coalition and the Chicago Recovery Alliance
Canada-focused information can be found at the Street Works Web site
The Harm Reduction Journal publishes open-access articles
The CDC has a web page on eliminating racial and ethnic health disparities
The Drug Policy Alliance has a web page on drug policy in the United States
doi:10.1371/journal.pmed.0030452
PMCID: PMC1621100  PMID: 17076569
4.  Stigmatizing Attitudes towards Mental Illness among Racial/Ethnic Older Adults in Primary Care 
Objective
The current study applies the perceived stigma framework to identify differences in attitudes toward mental health and mental health treatment among various racial/ethnic minority older adults with common mental health problems including depression, anxiety disorders, or at-risk alcohol use. Specifically, this study examines to what extent race/ethnicity is associated with differences in: (1) perceived stigma of mental illness; and (2) perceived stigma for different mental health treatment options.
Methods
Analyses were conducted using baseline data collected from participants who completed the SAMHSA Mental Health and Alcohol Abuse Stigma Assessment, developed for the PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly) study, a multi-site randomized trial for older adults (65+) with depression, anxiety, or at-risk alcohol consumption. The final sample consisted of 1247 non-Latino Whites, 536 African-Americans, 112 Asian-Americans, and 303 Latinos.
Results
African-Americans and Latinos expressed greater comfort in speaking to primary care physicians or mental health professionals concerning mental illness compared to non-Latino Whites. Asian-Americans and Latinos expressed greater shame and embarrassment about having a mental illness than non-Latino Whites. Asian-Americans expressed greater difficulty in seeking or engaging in mental health treatment.
Conclusions
Racial/ethnic differences exist among older adults with mental illness with respect to stigmatizing attitudes towards mental illness and mental health treatment. Results of this study could help researchers and clinicians educate racial/ethnic minority older adults about mental illness and engage them in much needed mental health services.
doi:10.1002/gps.3928
PMCID: PMC3672370  PMID: 23361866
race/ethnicity; stigma; older adults
5.  Identification of and Beliefs about Depressive Symptoms and Preferred Treatment Approaches Among Community-living Older African Americans 
Objective
To examine older African American’s recognition of and beliefs about depressive symptoms, preferred symptom management strategies, and factors associated with willingness to use mental health treatments. Differences between depressed and non-depressed and men and women were examined.
Design
Cross-sectional survey.
Setting
Home, senior center.
Participants
153 senior center members (56=males, 97=females) ≥55 years.
Measurements
Using a depression vignette, participants indicated if the person was depressed and their endorsement of items reflecting beliefs, stigma, symptom management, and willingness to use treatments (yes/no). PHQ-9 assessed current symptomatology.
Results
Overall, 24.2% reported depressive symptoms (≥5); 88.2% correctly identified the person in the vignette as depressed. Most (≥75%) endorsed active symptom management strategies, preference for treatment in physician and therapist offices, and willingness to take medications, seek therapy, see doctor and attend support groups; <33% viewed depression as stigmatizing whereas 48% viewed depression as normal aging. Logistic regressions revealed lower education, higher physical function and feeling okay if community knew of depression diagnosis were associated with willingness to see physician if feeling depressed; being married and believing anti-depressant medications are beneficial were related to willingness to use medications. Different associations emerged for depressed/non-depressed and men and women.
Conclusions
Overall, this older African American sample had positive attitudes and beliefs and endorsed traditional treatment modalities suggesting that beliefs alone are unlikely barriers to underutilization of mental health services. As different factors were associated with willingness to seek physician help and use medications and factors differed for depressed/non-depressed and by sex, interventions should be tailored.
doi:10.1097/JGP.0b013e31825463ce
PMCID: PMC4030409  PMID: 22643600
Depression; health disparities; depression beliefs
6.  African American Women's Beliefs, Coping Behaviors, and Barriers to Seeking Mental Health Services 
Qualitative health research  2009;19(11):1589-1601.
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.
doi:10.1177/1049732309350686
PMCID: PMC2854663  PMID: 19843967
African Americans; coping and adaptation; dimensional analysis; mental health and illness; stigma; women's health
7.  Older African American Women’s Lived Experiences with Depression 
Little is known about older African American women’s lived experiences with depression. What does depression mean to this group? What are they doing about their depression? Unfortunately, these questions are unanswered. This study examined older African American women’s lived experiences with depression and coping behaviours. The common sense model provided the theoretical framework for present study. Thirteen community-dwelling African American women aged 60 and older (M =71 years) participated. Using qualitative phenomenological data analysis, results showed the women held beliefs about factors that can cause depression including experiences of trauma, poverty, and disempowerment. Results also indicated the women believed that depression is a normal reaction to life circumstances and did not see the need to seek professional treatment for depression. They coped by use of culturally-sanctioned behaviours including religious practices and resilience. It appears these women’s beliefs about depression and use of culturally-sanctioned coping behaviours might potentially be a barrier to seeking professional mental health care, which could result in missed opportunities for early diagnosis and treatment of depression among this group. Implications for research, educational and clinical interventions are discussed.
doi:10.1111/jpm.12046
PMCID: PMC4114393  PMID: 23742034
8.  Improving engagement in mental health treatment for home meal recipients with depression 
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.2147/CIA.S49154
PMCID: PMC3790871  PMID: 24101866
depression; access to care; mental health intervention; engagement
9.  Perspectives on perceived stigma and self-stigma in adult male patients with depression 
There are two principal types of stigma in mental illness, ie, “public stigma” and “self-stigma”. Public stigma is the perception held by others that the mentally ill individual is socially undesirable. Stigmatized persons may internalize perceived prejudices and develop negative feelings about themselves. The result of this process is “self-stigma”. Stigma has emerged as an important barrier to the treatment of depression and other mental illnesses. Gender and race are related to stigma. Among depressed patients, males and African-Americans have higher levels of self-stigma than females and Caucasians. Perceived stigma and self-stigma affect willingness to seek help in both genders and races. African-Americans demonstrate a less positive attitude towards mental health treatments than Caucasians. Religious beliefs play a role in their coping with mental illness. Certain prejudicial beliefs about mental illness are shared globally. Structural modeling indicates that conformity to dominant masculine gender norms (“boys don’t cry”) leads to self-stigmatization in depressed men who feel that they should be able to cope with their illness without professional help. These findings suggest that targeting men’s feelings about their depression and other mental health problems could be a more successful approach to change help-seeking attitudes than trying to change those attitudes directly. Further, the inhibitory effect of traditional masculine gender norms on help-seeking can be overcome if depressed men feel that a genuine connection leading to mutual understanding has been established with a health care professional.
doi:10.2147/NDT.S54081
PMCID: PMC4122562  PMID: 25114531
stigma; self-stigma; depression; male gender
10.  Psychosocial, socio-cultural, and environmental influences on mental health help-seeking among African-American men 
Journal of men's health  2012;9(2):63-69.
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.
doi:10.1016/j.jomh.2012.03.002
PMCID: PMC3418821  PMID: 22905076
Social behavior; Minority health; Men’s health; Help-seeking; Mental health
11.  Religious Participation and DSM-IV Disorders among Older African Americans: Findings from the National Survey of American Life (NSAL) 
Objectives
This study examined the religious correlates of psychiatric disorders.
Design
The analysis is based on the National Survey of American Life (NSAL). The African American sample of the NSAL is a national representative sample of households with at least one African American adult 18 years or over. This study utilizes the older African American sub-sample (n=837).
Methods
Religious correlates of selected measures of lifetime DSM-IV psychiatric disorders (i.e., panic disorder, agoraphobia, social phobia, generalized anxiety disorder, obsessive compulsive disorder, posttraumatic stress, major depressive disorder, dysthymia, bipolar I & II disorders, alcohol abuse/dependence, and drug abuse/dependence) were examined.
Participants
Data from 837 African Americans aged 55 years or older are used in this analysis.
Measurement
The DSM-IV World Mental Health Composite International Diagnostic Interview (WMH-CIDI) was used to assess mental disorders. Measures of functional status (i.e., mobility and self-care) were assessed using the World Health Organization Disability Assessment Schedule-Second Version (WHODAS-II). Measures of organizational, non-organizational and subjective religious involvement, number of doctor diagnosed physical health conditions, and demographic factors were assessed.
Results
Multivariate analysis found that religious service attendance was significantly and inversely associated with the odds of having a lifetime mood disorder.
Conclusions
This is the first study to investigate the relationship between religious participation and serious mental disorders among a national sample of older African Americans. The inverse relationship between religious service attendance and mood disorders is discussed. Implications for mental health treatment underscore the importance of assessing religious orientations to render more culturally sensitive care.
doi:10.1097/JGP.0b013e3181898081
PMCID: PMC2631206  PMID: 19038894
Church Attendance; Depression; Mood Disorder
12.  Illness Conceptualizations among Older Rural Mexican-Americans with Anxiety and Depression 
Background
Research on barriers and utilization of mental health services in older ethnic minorities has been productive. However, little is known about the characterization and beliefs about anxiety and depression symptoms among older Mexican-Americans. Exploration of these conceptualizations will lead to better detection and provision of care to this large, yet underserved group.
Method
The present study used a mixed methods approach to explore conceptualizations of anxiety and depression in a group of rural older Mexican-Americans. Twenty-five Spanish-speaking participants (mean age 71.2) responded to flyers that solicited individuals who felt “tense or depressed.” Participants completed a structured diagnostic interview as well as self-report questionnaires about medical health, anxiety and depressive symptoms, and cognitive functioning. Qualitative interviews included questions about how participants describe, conceptualize, and cope with anxiety and depression symptoms.
Results
Sixty-eight percent of the sample met criteria for at least one anxiety or mood disorder with high comorbidity rates. Self-reported symptoms of depression, anxiety, and somatization were below clinical ranges for all participants. Medical illness, cognitive impairment, age, education, and acculturation were not associated with distress. Qualitative analyses revealed that nearly half of the terms used by the sample to describe distress phenomena deviated from Western labels traditionally used to indicate anxious and depressive symptomatology.
Discussion
Multiple methods of symptom endorsement demonstrated that older Mexican-Americans may report distress differently than detected by traditional self-report measures or common Western terminology. Understanding these additional illness conceptualizations may have implications for improving the detection of mental illness and increasing service use among this growing population.
doi:10.1007/s10823-013-9211-8
PMCID: PMC3948319  PMID: 24077906
acculturation; elderly; rural mental health; idioms of distress
13.  The Mental Health Needs of Out-of-School Adolescents and Young Adults: An Intervention Conducted in Employment Training Programs, Baltimore, Maryland, 2007-2008 
Introduction
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.
Methods
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.
Results
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.
Conclusion
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.
PMCID: PMC3368697  PMID: 22405476
14.  Late middle-aged and older men living with HIV/AIDS: race differences in coping, social support, and psychological distress. 
Although AIDS mental health research has recently devoted more attention to the psychosocial needs of older adults living with human immunodeficiency virus (HIV) disease, studies of this population have typically combined older African-American and white participants into one large sample, thereby neglecting potential race differences. The current study examined race differences in stressor burden, ways of coping, social support, and psychological distress among late middle-aged and older men living with HIV/AIDS. Self-administered surveys were completed by 72 men living with HIV/AIDS in New York City and Milwaukee, WI (mean age = 53.4 years). Older African-American and white men experienced comparable levels of stress associated with AIDS-related discrimination, AIDS-related bereavement, financial dilemmas, lack of information and support, relationship difficulties, and domestic problems. However, in responses to these stressors, older African-American men more frequently engaged in adaptive coping strategies, such as greater positive reappraisal and a stronger resolve that their future would be better. Compared to their African-American counterparts, HIV-infected older white men reported elevated levels of depression, anxiety, interpersonal hostility, and somatization. African-American men also received more support from family members and were less likely to disclose their HIV serostatus to close friends. As AIDS becomes more common among older adults, mental health-interventions will increasingly be needed for this group. The development of intervention programs for this group should pay close attention to race-related differences in sociodemographic, psychosocial, and behavioral characteristics.
PMCID: PMC2608530  PMID: 11052457
15.  African American Men and Women's Attitude Toward Mental Illness, Perceptions of Stigma, and Preferred Coping Behaviors 
Nursing research  2013;62(3):185-194.
Background
Although research focused on African Americans with mental illness has been increasing, few researchers have addressed gender and age differences in beliefs, attitudes, and coping.
Objective
To examine African Americans' beliefs about mental illness, attitudes toward seeking mental health services, preferred coping behaviors, and whether these variables differ by gender and age.
Method
An exploratory, cross-sectional survey design was used. Participants were 272 community-dwelling African Americans aged 25-72 years. Data analysis included descriptive statistics and general linear regression models.
Results
Depression was the most common mental illness and there were no gender differences in prevalence. Both men and women believed they knew some of the symptoms and causal factors of mental illness. Their attitudes suggested they are not very open to acknowledging psychological problems, are very concerned about stigma associated with mental illness, and are somewhat open to seeking mental health services, but they prefer religious coping. Significant gender and age differences were evident in attitudes and preferred coping.
Discussion
Our findings have implications for gender and age-specific psychoeducation interventions and future research. For instance, psychoeducation or community awareness programs designed to increase openness to psychological problems and reducing stigma are needed. Also, exploration of partnerships between faith-based organizations and mental health services could be helpful to African Americans.
doi:10.1097/NNR.0b013e31827bf533
PMCID: PMC4279858  PMID: 23328705
African Americans; mental illness; beliefs; coping behaviors
16.  Cultural Beliefs and Mental Health Treatment Preferences of Ethnically Diverse Older Adult Consumers in Primary Care 
Background
Beliefs concerning the causes of mental illness may help explain why there are significant disparities in the rates of formal mental health service use among racial/ethnic minority elderly as compared with their Caucasian counterparts. This study applies the Cultural Influences on Mental Health framework to identify the relationship between race/ethnicity and differences in: (1) beliefs on the cause of mental illness; (2) preferences for type of treatment; and (3) provider characteristics.
Method
Analyses were conducted using baseline data collected from participants who completed the Cultural Attitudes toward Healthcare and Mental Illness Questionnaire, developed for the PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly) study, a multi-site randomized trial for older adults (65+) with depression, anxiety, or at-risk alcohol consumption. The final sample consisted of 1257 non-Latino Whites, 536 African-Americans, 112 Asian-Americans, and 303 Latinos.
Results
African-Americans, Asian-Americans, and Latinos had differing beliefs regarding the causes of mental illness when compared to Non-Latino Whites. Race/ethnicity was also associated with determining who makes healthcare decisions, treatment preferences, and preferred characteristics of healthcare providers.
Conclusions
This study highlights the association between race/ethnicity and health beliefs, treatment preferences, healthcare decisions, and consumers' preferred characteristics of healthcare providers. Accommodating the values and preferences of individuals can be helpful in engaging racial/ethnic minority patients in mental health services.
doi:10.1097/JGP.0b013e318227f876
PMCID: PMC3258470  PMID: 21992942
race/ethnicity; health beliefs; older adults
17.  Initial Evidence of Religious Practice and Belief in Depressed African American Cancer Patients 
Objective:
This study examined spiritual coping (beliefs and practices) of depressed African American cancer patients through a comparison with depressed White cancer patients and non-depressed African American cancer patients.
Methods:
Using mixed methods, 74 breast (n=41) and prostate (n=33) cancer survivors including 34 depressed and 23 nondepressed African Americans and 17 depressed Whites were interviewed. The interviews were audiotaped and transcribed. Qualitative data analysis identified themes that were coded. The codes were entered into SPSS software. The Fisher’s exact test was performed to examine group differences in self-reported spiritual coping.
Results:
Significantly more depressed African Americans questioned God when learning of a cancer diagnosis than the non-depressed African Americans (p=.03), but they did not differ from the depressed Whites in this regard (p=.70). Significantly more depressed African Americans reported having faith in God (p=.04), reading the bible (p=.02), and conversing with God (p=.01) than did the depressed Whites. They also reported praying alone (p=.01) more frequently than the depressed Whites who, on the other hand, reported praying with others (non-family members) together for one’s own health more frequently (p=.04).
Conclusions:
Depression is associated with a deepening need for spirituality and it affects religious beliefs and practices more in African American than White cancer patients. Given its important role in the lives of African American cancer patients, spirituality may be utilized as a reasonable, culturally-based approach to better assess and treat depression in these patients.
doi:10.2174/1874434601307010001
PMCID: PMC3551236  PMID: 23346265
African American; cancer; depression; race; pray; religion; spirituality.
18.  Depression in African American Men: A Review of What We Know and Where We Need to Go From Here 
The American journal of orthopsychiatry  2013;83(2 0 3):386-397.
Depression is one of the most common mental disorders in the United States and affects an estimated 17 million people each year. Projections about depression have generated concern on both the domestic and global levels because of its impact on health outcomes and quality of life. We examined and summarized published research focusing on depression among African American men with the goal of identifying prevalence of depression, risk factors, treatment-seeking behaviors, and treatment-seeking barriers. In the use of a systematic review, inclusion criteria were studies focused on depression among African American or Black men, separated analysis by race and gender, and conducted in the United States. Each study was critically reviewed to identify depression prevalence, risk factors, treatment-seeking behaviors, and barriers. Only 19 empirical studies focusing on depression among African American men were identified in a 25-year time span. Findings suggest the prevalence of depression among African American men ranges from 5% to 10%, they face a number of risk factors, yet evidence low use of mental health services. Consequently, depression among African American men needs to be at the forefront of our research, practice, and outreach agendas. A focus on this group has the potential to reduce mental health disparities experienced by African American men.
doi:10.1111/ajop.12015
PMCID: PMC4215700  PMID: 23889029
African American men; depression; racial discrimination; work stressors; retirement; socioeconomic positioning; poverty; social network; mental illness; alcohol abuse; Afrocentric cultural values
19.  A cluster randomized trial of standard quality improvement versus patient-centered interventions to enhance depression care for African Americans in the primary care setting: study protocol NCT00243425 
Background
Several studies document disparities in access to care and quality of care for depression for African Americans. Research suggests that patient attitudes and clinician communication behaviors may contribute to these disparities. Evidence links patient-centered care to improvements in mental health outcomes; therefore, quality improvement interventions that enhance this dimension of care are promising strategies to improve treatment and outcomes of depression among African Americans. This paper describes the design of the BRIDGE (Blacks Receiving Interventions for Depression and Gaining Empowerment) Study. The goal of the study is to compare the effectiveness of two interventions for African-American patients with depression--a standard quality improvement program and a patient-centered quality improvement program. The main hypothesis is that patients in the patient-centered group will have a greater reduction in their depression symptoms, higher rates of depression remission, and greater improvements in mental health functioning at six, twelve, and eighteen months than patients in the standard group. The study also examines patient ratings of care and receipt of guideline-concordant treatment for depression.
Methods/Design
A total of 36 primary care clinicians and 132 of their African-American patients with major depressive disorder were recruited into a cluster randomized trial. The study uses intent-to-treat analyses to compare the effectiveness of standard quality improvement interventions (academic detailing about depression guidelines for clinicians and disease-oriented care management for their patients) and patient-centered quality improvement interventions (communication skills training to enhance participatory decision-making for clinicians and care management focused on explanatory models, socio-cultural barriers, and treatment preferences for their patients) for improving outcomes over 12 months of follow-up.
Discussion
The BRIDGE Study includes clinicians and African-American patients in under-resourced community-based practices who have not been well-represented in clinical trials to improve depression care. The patient-centered and culturally targeted approach to depression care is a relatively new one that has not been tested in most previous studies. The study will provide evidence about whether patient-centered accommodations improve quality of care and outcomes to a greater extent than standard quality improvement strategies for African Americans with depression.
Trial Registration
ClinicalTrials.gov NCT00243425
doi:10.1186/1748-5908-5-18
PMCID: PMC2838803  PMID: 20178624
20.  Family Matters: The Role of Mental Health Stigma and Social Support on Depressive Symptoms and Subsequent Help Seeking Among African American Boys 
The Journal of black psychology  2010;36(4):458-482.
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.
doi:10.1177/0095798409355796
PMCID: PMC2953262  PMID: 20953336
help seeking; stigma; social support; depression; African American adolescent boys
21.  “Church-Based Health Programs for Mental Disorders among African Americans: A Review 
Objective
African Americans, compared to White Americans, underutilize traditional mental health services. A systematic review is presented of studies involving church-based health promotion programs (CBHPP) for mental disorders among African Americans to assess the feasibility of utilizing such programs to address racial disparities in mental health care.
Methods
A literature review of MEDLINE, PsycINFO, CINAHL, and ATLA Religion databases was conducted to identify articles published between January 1, 1980 and December 31, 2009. Inclusion criteria included the following: studies were conducted in a church; primary objective(s) involved assessment, perceptions/attitudes, education, prevention, group support, or treatment for Diagnostic and Statistical Manual-IV mental disorders or their correlates; number of participants was reported; qualitative and/or quantitative data were reported; and African Americans were the target population.
Results
Of 1,451 studies identified, 191 studies were eligible for formal review. Only eight studies met inclusion criteria for this review. The majority of studies focused on substance related disorders (n=5), were designed to assess the effects of a specific intervention (n=6), and targeted adults (n=6). One study focused on depression and was limited by a small sample size of seven participants.
Conclusion
Although CBHPP have been successful in addressing racial disparities for several chronic medical conditions, the published literature on CBHPP for mental disorders is extremely limited. More intensive research is needed to establish the feasibility and acceptability of utilizing church-based health programs as a possible resource for screening and treatment to improve disparities in mental health care for African Americans.
doi:10.1176/appi.ps.201100216
PMCID: PMC3952019  PMID: 22388529
22.  Disparities in Mental Health Treatment Following the World Trade Center Disaster: Implications for Mental Health Care and Health Services Research 
Journal of traumatic stress  2005;18(4):287-297.
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.
doi:10.1002/jts.20039
PMCID: PMC2694751  PMID: 16281225
23.  A study of a culturally focused psychiatric consultation service for Asian American and Latino American primary care patients with depression 
BMC Psychiatry  2011;11:166.
Background
Ethnic minorities with depression are more likely to seek mental health care through primary care providers (PCPs) than mental health specialists. However, both provider and patient-specific challenges exist. PCP-specific challenges include unfamiliarity with depressive symptom profiles in diverse patient populations, limited time to address mental health, and limited referral options for mental health care. Patient-specific challenges include stigma around mental health issues and reluctance to seek mental health treatment. To address these issues, we implemented a multi-component intervention for Asian American and Latino American primary care patients with depression at Massachusetts General Hospital (MGH).
Methods/Design
We propose a randomized controlled trial to evaluate a culturally appropriate intervention to improve the diagnosis and treatment of depression in our target population. Our goals are to facilitate a) primary care providers' ability to provide appropriate, culturally informed care of depression, and b) patients' knowledge of and resources for receiving treatment for depression. Our two-year long intervention targets Asian American and Latino American adult (18 years of age or older) primary care patients at MGH screening positive for symptoms of depression. All eligible patients in the intervention arm of the study who screen positive will be offered a culturally focused psychiatric (CFP) consultation. Patients will meet with a study clinician and receive toolkits that include psychoeducational booklets, worksheets and community resources. Within two weeks of the initial consultation, patients will attend a follow-up visit with the CFP clinicians. Primary outcomes will determine the feasibility and cost associated with implementation of the service, and evaluate patient and provider satisfaction with the CFP service. Exploratory aims will describe the study population at screening, recruitment, and enrollment and identify which variables influenced patient participation in the program.
Discussion
The study involves an innovative yet practical intervention that builds on existing resources and strives to improve quality of care for depression for minorities. Additionally, it complements the current movement in psychiatry to enhance the treatment of depression in primary care settings. If found beneficial, the intervention will serve as a model for care of Asian American and Latino American patients.
Trial Registration
ClinicalTrials.gov: NCT01239407
doi:10.1186/1471-244X-11-166
PMCID: PMC3209439  PMID: 21995514
24.  Late-life Depression in Older African Americans: A Comprehensive Review of Epidemiological and Clinical Data 
Objective
The population of older African Americans is expected to triple by 2050, highlighting the public health importance of understanding their mental health needs. Despite evidence of the negative impact of late-life depression, less is known of how this disorder affects the lives of older African Americans. Lack of studies focusing on how depression presents in older African Americans and their subsequent treatment needs lead to a gap in epidemiologic and clinical knowledge for this population. In this review, we aim to present a concise report of prevalence, correlates, course, outcomes, symptom recognition, and treatment of depression for these individuals.
Method
We performed a literature review of English-language articles identified from PubMed and Medline published between January 1990 and June 2012. Studies included older adults and contained the key words “geriatric depression in African Americans,” “geriatric depression in Blacks,” and geriatric depression in minorities.”
Results
Although in most studies older African Americans had higher or equivalence prevalence of depression compared to Caucasian Americans, we also found lower rates of recognition of depression and treatment. Many studies reported worse outcomes associated for depression among older African Americans compared older Caucasians.
Conclusions
Serious racial and ethnic disparities persist in the management of older African Americans with depression. Understanding their unmet needs and improving depression care for these individuals is necessary to reduce these disparities.
doi:10.1002/gps.3908
PMCID: PMC3674152  PMID: 23225736
Late-life Depression; Race; African Americans
25.  Perceptions of Support Among Older African American Cancer Survivors 
Oncology nursing forum  2010;37(4):484-493.
Purpose/Objectives
To explore the perceived social support needs among older adult African American cancer survivors.
Research Approach
Qualitative design using grounded theory techniques.
Setting
Outpatient oncology clinics in the southeastern United States.
Participants
Focus groups with 22 older adult African American cancer survivors.
Methodologic Approach
Purposeful sampling technique was used to identify focus group participants. In-depth interviews were conducted and participants were interviewed until informational redundancy was achieved.
Main Research Variables
Social support needs of older adult African American patients with cancer.
Findings
Social support was influenced by (a) symptoms and treatment side effects, (b) perceptions of stigma and fears expressed by family and friends, (c) cultural beliefs about cancer, and (d) desires to lessen any burden or disruption to the lives of family and friends. Survivors navigated within and outside of their networks to get their social support needs met. In some instances, survivors socially withdrew from traditional sources of support for fear of being ostracized. Survivors also described feeling hurt, alone, and socially isolated when completely abandoned by friends.
Conclusions
The support from family, friends, and fellow church members is important to positive outcomes among older African American cancer survivors. However, misconceptions, fears, and negative cultural beliefs persist within the African American community and negatively influence the social support available to this population.
Interpretations
Early identification of the factors that influence social support can facilitate strategies to improve outcomes and decrease health disparities among this population.
doi:10.1188/10.ONF.484-493
PMCID: PMC2948788  PMID: 20591808

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