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Racial and ethnic differences in depression:

current perspectives
This article was published in the following Dove Press journal:
Neuropsychiatric Disease and Treatment

Rahn Kennedy Bailey Abstract: Major depressive disorder (MDD) is among the most prevalent disorders in the US
Josephine Mokonogho that often goes underdiagnosed and untreated. The burden of disability among those untreated
Alok Kumar is heaviest among untreated minority populations. Recent studies show that among African
Americans, those with socioeconomic stress are less likely to report psychological symptoms or
Department of Psychiatry, Wake
Forest School of Medicine, remain compliant with initiated treatment. While minority populations are less likely to suffer
Winston-Salem, NC, USA from acute episodes of MDD than Caucasians, they are more likely to suffer from prolonged,
chronic, and severely debilitating depression with heavy consequences on their level of daily
functioning. Part of the problem of underdiagnoses lies with the provider. Many providers today
are unable to notice subtleties in presentation or recognize uncommon presentation of disease.
This paper focuses on discrepancies in the presentation of depression among minorities when
compared to Caucasians as well as factors that serve as boundaries for successful treatment.
Keywords: minorities, depression, African American, chronic, disparities, ethnic

Introduction
Depression is a disease that straddles all genders, ethnicities, races, and walks of
life. Studies have shown that of the roughly 18 million Americans who struggle with
mood disorders, approximately ten million of these individuals suffer from major or
clinical depression. Of these ten million individuals, roughly two-thirds go without
treatment. The disease is multifactorial and can be attributed to genetic causes, various
psychosocial and environmental stressors, and can be an unpleasant accompaniment
to a variety of other diseases and disease processes. The pathogenesis of disease has
previously been described as involving three general sets of risk factors: 1) internal-
izing factors such as genetics, 2) externalizing factors such as medication side effects/
secondary to underlying illnesses and substance abuse, and 3) adversity due to trauma
and psychosocial stressors such as low socioeconomic position. Those with first-degree
relatives with the disorder are at a 1.5 to 3-time increase in risk than those among the
general population. When exploring disparities in depression across racial and ethnic
boundaries, it is important to consider 1) the differences in predisposing factors (ie,
genetic factors and adverse childhood events), 2) the presentation of disease, and
3) boundaries to sustained and successful treatment. For the purposes of this article,
Correspondence: Rahn Kennedy Bailey; we will explore discrepancies in the presentation of depression among minorities when
Alok Kumar compared to Caucasians as well as factors that serve as boundaries for ethnic minor-
2656 South Loop West, Suite 250,
Houston, TX 77054, USA ity patients in initiating treatment and sustaining a long-term, disease-free existence.
Tel +1 336 716 2911 Studies that have explored the prevalence and distribution of major depressive
Fax +1 336 716 1400
Email [email protected];
disorder in African Americans, non-Hispanic Caucasians Americans and Caribbean
[email protected] African Americans have found that overall lifetime prevalence of major depressive

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http://dx.doi.org/10.2147/NDT.S128584
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disorder among Caucasians was 17.9% as opposed to socioeconomic position and depression. Studies have examined
African Americans, whose prevalence estimate was only the relationship between socioeconomic position and depres-
10.4%.1 The difference between African Americans and sion in the African American community. One study in particu-
Caucasians lies in the fact that the chronicity of disease lar found that household income and unemployment predicted
was higher for African Americans (56%) than it was for greater odds of major depressive episodes among African
Caucasian patients (38.6%).1 Among this percentage, fewer Americans and an inverse relationship between education
than half of these African Americans sought treatment for level and a 12-month major depressive episode. Additionally,
their depression, although when asked to qualify their dis- an inverse relationship between income and 12-month major
ease, they would rate their condition as severe or disabling.1 depressive episode (MDE) was noted in African American,
Thus, this study concluded that the burden of depression was particularly in women.5 In addition to socioeconomic factors,
shouldered more heavily on African Americans than it was home environment was also assessed for risk of depression
on Caucasians in the United States, leading to an overall in African Americans. Thus far, no concrete data has shown
greater degree of functional impairment. Some studies argue that African Americans in single-parent households are more
that African Americans may have lower rates of depression susceptible to depression later in life than those in two-parent
when compared to non-Hispanic Caucasians due to the resil- families.3 However, evidence from these studies has shown
ient nature of the community and greater religious support, that higher parental education correlated to greater adult
but even these studies agree that these patients often tend achievement and self-esteem in African Americans, especially
to be underdiagnosed or misdiagnosed.2 These studies also in African American men, and lower depression.3 Another
acknowledge that African Americans who are diagnosed study looked at how neighborhood ethnic composition related
with depression often tend to have more serious, chronic, to mental health among African Americans. Results suggested
and severely debilitating disease.2 that as same-ethnicity neighborhood composition increased,
When examining risk factors for depression in African rates of depression decreased.3 The study used the Center
Americans, studies have focused on the role of discrimina- for Epidemiologic Studies-Depression instrument to show
tion as a major potential risk factor for MDD in the African that neighborhood ethnic composition was a prominent risk
American community. Self-perceived racial discrimination, in factor among African Americans for depression (24%) when
particular, has been strongly associated with worsening mental compared to Caucasians (14%).3
and physical health, more so in African American women than There is a known association between stressful life events
in men.3 By contrast, a strong sense of ethnic identity among (SLEs) and depression. SLE can be seen in racial minorities
African Americans has been shown to be a protective factor from lower socioeconomic backgrounds, whose lives are com-
against mental illness in these communities.4 Ethnic identity pounded by abject or perceived racism, a dearth of education,
is defined as a sense of commitment and belonging to an communal violence, single-family households, or substance
ethnic group, positive feelings about the group, and behaviors abuse. One cross-sectional study examined how SLEs are
that indicate involvement with the ethnic group.4 There are determined by race and gender in a sample of 5,899 adults.6 Of
future studies aimed at examining cultural and ethnic identity these 5,899 adults, 5,008 were African American or Caribbean
among clinical samples in an attempt to gain a better sense of Blacks. Non-Hispanic Caucasians made up the remainder
how positive ethnic identity can be fostered and strengthened of the sample. SLE in the past 30 days was the independent
among members of the community in an attempt to protect variable. Twelve-month MDE was used as the dependent
against mental illness.4 In addition to ethnicity and gender, variable, with factors such as age, educational level, marital
risk factors such as lower yearly income, socioeconomic status, employment, and region as controls.6 The results of
positioning, poverty status, and employment are recognized the study suggested a stronger association between SLE and
as key risk factors.3 This suggests that marriage and a higher MDE among Caucasian men compared to African American
level of income and education are protective factors in the or Caribbean black men. However, there was no statisti-
African American community for depression. Job security, for cally significant difference between Caucasian and African
example, was found to be associated with fewer depressive American women.6 While this study demonstrated a possible
symptoms in African American men than in Caucasians or stronger association between SLE and MDE in Caucasian
Hispanic communities.3 men, the sample size of 891 Caucasians to 5008 African
When discussing disparities in depression among ethnic Americans or Caribbean individuals cannot be ignored.
minorities, one should consider the relationship between Although control factors such as educational level, marital

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Dovepress Bailey et al

status etc. were addressed, a larger sample size of Caucasian Another study utilized data from the National Survey of
patients may have afforded researchers reliable results. American Life – Adolescent Supplement (NSAL-A) from
Researchers have examined lower socioeconomic status 2003–2004 to study the link between education and depres-
as a risk factor for MDD among racial and ethnic minorities. sion in African Americans and Caribbean Blacks.10 This
One study examined the prevalence of MDD in 1,117 black study concluded that higher education was associated with
adolescents, 810 African Americans, and 360 Caribbean a lower risk of depression in African Americans, both male
blacks, with high household income as the main predictor and female.10 The study concluded that further research was
and MDD as the main outcome.7 These results showed that needed to investigate how additional factors such as culture
higher household income was a protective factor against or life experiences influence the presence of future depres-
MDD for Caribbean blacks and for females than for African sive symptoms.
Americans males.7 African American males were at higher Additionally, Lankarani and Assari looked at positive and
odds of developing lifetime, 12-month, and 30-day MDD.7 negative emotions as predictors of chronic medical conditions
This study demonstrates how SES fails to protect African in African Americans and Caucasians.11 The study found that
Americans when it comes to chronic, debilitating MDD. although adversity is more common in African American
Further disparities between minority populations and communities, based on the Black versus Caucasian health
Caucasians were found in studies examining the asso- paradox, African Americans less frequently exhibit depressive
ciation between MDD symptoms and the presence of other symptoms as opposed to Caucasians.11 The study examines
comorbid chronic medical conditions.8 The researchers in the “undoing hypothesis,” which asserts that positive emo-
this study found weaker associations between MDD and tions act as a buffer to undo the harmful effects of negative
chronic medical conditions for African Americans when ones.11 The researchers assert that African Americans are
compared to Caucasians.8 The data for this study came from found to have higher levels of hopefulness. This explains
the Americans’ Changing Lives Study, which followed why African Americans are less likely to exhibit depressive
patients from 1986 to 2011. The results were based on self- symptoms than Caucasians. Depressive symptoms are better
reporting physician diagnoses at the start of the study and a predictors of future MDD for Caucasians rather than for
follow-up 25 years later.8 Based on the respondents’ answers, African Americans, despite overall higher levels of stress in
chronic conditions such as hypertension, diabetes, chronic African Americans.11 In another study, Assari and Lankarani
lung disease, chronic heart disease, etc. were tabulated. compared African Americans with Caucasians, examin-
Researchers used a 10-item Center for Epidemiological ing the correlation between feelings of hopelessness and
Studies-Depression (CES-D) scale followed by multi-group depression.12 The researchers discuss how hopelessness and
structural equation modeling to assess associations between optimistic attitudes vary between ethnicities. They concluded
subsequent MDD symptoms and chronic medical conditions that depressive symptoms are associated with hopelessness
among Caucasian and African American patients. in Caucasians more than in African Americans.12 They offer
Certain studies have examined the role of various socio- treatment recommendations based on these conclusions, spe-
economic factors like education in the predictive role on cifically the idea of burgeoning a positive attitude in therapy
depressive symptoms.9 This prospective study utilized a life- to counter depression among Caucasians. African Americans
course approach to compare African American and Caucasian with depression have a tendency to maintain positive attitudes
males and females to assess the impact of .12 years contin- in the face of adversity and foster hope.
ued education on future depressive symptoms from baseline Studies have sought to examine what has been described
to up to 25 years.9 African American males were the only as the two contradictory assumptions underlying research on
group not to exhibit a net protective effect of education on race differences in psychiatric diagnosis. The first assump-
the development of chronic medical conditions, including tion is the “clinician bias” hypothesis, which makes the
depression.9 While education was protective to an extent, assumption that each race exhibits depressive symptoms
a threshold effect of continued education was found over similarly and the fault in misdiagnosis lies with the clinician,
follow-up to have an increase in depressive symptoms as well. who judges each race differently.13 The other hypothesis is
The study paradoxically concluded that although education described as “cultural relativity,” which assumes that depres-
was beneficial for African American men, those graduating sion manifests differently in various racial minorities when
with a high school diploma were at additional risk for devel- compared to Caucasians and the clinician is insensitive to the
opment of depressive symptoms over a 25-year follow-up.9 cultural differences between each ethnic group, leading to a

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misdiagnosis.13 These older studies support the idea of cultural in primary care settings.15 Studies examining disparities in
relativity, that the clinician himself is unaware and hence mental health care for primary care and psychiatry showed
unable to properly diagnose depression in a racial minority continuing disparities in diagnoses, counseling/referrals for
due to his own shortcomings and lack of understanding. Stud- counseling, and antidepressant medication in primary care
ies exploring the notion that the clinician himself is unaware visits.15 After accounting for disparities in diagnosis and
of cultural differences have discussed a tool known as the treatment modalities among the two preferred avenues of
Patient-Centered Culturally Sensitive Health Care model care provided by primary care physicians and by special-
(PC-CSHC model).3 The PC-CSHC model was developed ists, further disparities in treatment were complicated by
to help clinicians and providers in promoting culturally sen- educational, linguistic, and cultural barriers.15
sitive health care practices, leading to a higher level of care Studies have examined what has been described as
for minorities and reducing disparities in treatment between systemic racism in the medical community and have con-
minorities and non-minorities. This model leads to a clini- cluded that many Americans of color have restricted access
cian’s greater understanding of disparities across race and eth- to adequate care and resources due to racialized framing on
nicity, leading to a more individually focused treatment that the part of the provider. Pain is a subjective entity that varies
works within the limitations of the patient’s cultural frame- from patient to patient and studies have concluded that it
work to provide higher level of care and, as a result, higher may be susceptible to social psychological influences like
level of patient satisfaction and adherence to treatment plans.3 negative racial stereotypes that may guide the provider’s
Studies have also shown differences in presenting symptoms judgment.16 In a study published in 2016 conducted at the
between African Americans and non-Hispanic Caucasians, University of Virginia, researchers examined the role of racial
with one study highlighting the presence of the symptom bias in the assessment and treatment of racial minorities to
of negative affect and interpersonal problems domains as a Caucasians by examining false beliefs held by members
harbinger of depressive disorder in African Americans. The of the health care community about biological differences
presence of these strongly predicts depressive disorders in between African Americans and Caucasians.17 This series of
African Americans more than in Caucasians.14 studies looked in particular at false beliefs regarding pain as
In addition to discussing boundaries to proper diag- experienced by African Americans versus Caucasians held by
nosis of depression, one must also explore boundaries Caucasian medical students and residents and found that half
to treatment of disease. When exploring boundaries to of their sample endorsed these false beliefs (ie, that African
sustained and successful treatment of depression among Americans have thicker skin than Caucasians), which in turn
African Americans, it is important to consider dispari- informed their medical judgment and treatment plans.17 Also,
ties in treatment of depression in different health care it is important to consider the perception among many that
settings – predominantly in a primary care setting as opposed racial minorities are somehow more immune to pain, be it
to a psychiatric setting. Over the years, a greater number of mental or physical, than Caucasians – the idea that simply
primary care physicians have been using pharmacological by virtue of the challenges minorities face in American
means by which to treat patients for psychiatric disorders society on a daily basis that their threshold for psychologi-
such as depression. This shift from specialized care under cal pain is greater. A provider working with this assumption
a trained psychiatrist to a primary care setting may pres- may minimize the minority patient’s symptoms leading to
ent a large disparity in not only recognizing the disease misdiagnosis. Expanding on this notion of negative racial
process in certain patients, but also in treatment modali- stereotypes, minority patients may not be taken seriously
ties used to varying degrees of success. In a primary care by the provider working under the assumption that the moti-
setting, disparities in treatment may result from failure to vating goal for the patient is secondary gain. For example,
properly detect depression or anxiety in minority patients.15 a provider may be under the incorrect assumption that a
In addition to failing to recognize depression, primary care minority patient may falsely exhibit signs and symptoms of
physicians may be amenable to prescribing medication to anxiety in an effort to obtain medication with potential for
treat symptoms perceived to be indicative of depression, abuse. Studies attempting to gauge the extent of health care
while patients may experience the benefits of one-on-one provider bias toward racial minorities has also had its limita-
or group therapy in addition to pharmacological treatment tions.18 Studies have found that when attempting to ascertain
for a sustained remission of disease. Furthermore, ethnic provider bias through direct questionnaire-based methods,
minorities are far less likely to be seen in psychiatry than there is a strong social desirability bias that guides providers’

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Dovepress Bailey et al

answers to question such as “When working with minority will purchase insurance through these provisions by 2022.20
individuals, I am confident that my conceptualization of cli- Under the ACA, the number of privately insured individu-
ent problems do not consist of stereotypes and biases”18 This als who will have access to medications and specialists was
“social desirability bias” threatens the validity of answers planned to increase, especially for racial and ethnic minori-
provided. Studies have opined that it may be possible to ties.20 Some studies looking at antidepressant usage between
reduce such a bias through computer-based questionnaires 2006 and 2010 among minorities found that disparities existed
that rely on the subject’s speed in answering questions posed even despite adequate coverage, disparities that have been
by relying on “gut reaction” to a posed question.18 Review slowly reduced over time due to interventions such as one-
articles have suggested that stereotyping of a minority on-one outreach, patient education, and translation services.20
patient by a provider is not a cognitive process that can be While insurance expansion itself will not account for dispari-
quantified or suppressed, but should be taken into account ties in the quality of care provided by primary care physicians
when discussing general barriers in successfully treating versus psychiatrists (ie, misdiagnoses and different treatment
minorities.18 These ingrained biases and stereotypes may modalities in successfully treated depression will continue
be countered through further provider education as well as to exist), the number of patients diagnosed with depression
increased awareness that such prejudices exist and may play should have an increased and easier access to antidepressant
a role in clinical judgment and treatment plans. medication as a result of the ACA.20 Today, under the current
Further, perceived discrimination plays a significant role administration, there is a potential for revision or repeal of
in depression among African American youth. Assari et al the ACA which would have a devastating impact on health
determined that racial discrimination plays a role in the over- care gains for previously uninsured Americans. If this comes
all mental health of African Americans. Increased anxiety to fruition, many millions of Americans will lose their health
due to an increased negative psychological stress response insurance, including those populations heavily dependent on
to perceived discrimination is prevalent among African Medicaid who have benefitted from the Medicaid expansions
American youth.19 This may lead to feelings of frustration provided by the passage of the ACA. Just one of countless
among youth, leading to increased participation in unhealthy examples of how this will affect mental health patients can
behaviors.19 Further, racial discrimination has been found to be found in looking at incarcerated populations in the US,
shorten telomere length, which has been found to be associ- many of whom suffer from chronic physical and mental
ated with premature aging.19 Assari et al concede that their health issues, substance abuse disorders, etc.21 This already-
study had limitations, including not accounting for gender or marginalized patient population, of which many are from
likelihood of seeking psychiatric treatment in these popula- racial and ethnic minority groups, will essentially be left in
tions. Nevertheless, prior studies have found that African the dark were the ACA to be repealed, finding themselves
American males are particularly vulnerable to depression not only without existing gains afforded under the ACA,
following perceived racial discrimination.19 but also without coverage altogether.21 Repealing the ACA
Another factor to consider when discussing disparities will further widen the already-daunting gap in mental health
in depression across racial and ethnic barriers is that of treatment between majority groups and minorities perhaps to
affordability of care and availability of resources. Despite such an extent that bridging the gap may seem futile. Already
overall growth in antidepressant treatment to alleviate more existing boundaries to treatment for mental health disorders,
severe and hindering symptoms of depression, studies show substance abuse disorders, etc. will be further burgeoned by
persistent racial and ethnic disparities in medication use repeal or revision of the ACA.
among Hispanics and African Americans when compared to Another important aspect when examining barriers to
Caucasians.20 Lack of health insurance and access to proper treatment for depression in minority communities is the
resources among these communities plays a culprit and acts as willingness of patients suffering from depression to seek help
a barrier to treatment.20 Recently, the emergence of the Afford- from outside sources. Some studies that have examined the
able Care Act sought to level the playing field and narrow the relationship among race/ethnicity and use of mental health
discrepancy gap between underprivileged communities and services available have shown that African American men
financially thriving ones. The Affordable Care Act made it (30%) in particular with depression are more reticent to use
possible, through the provision of federal subsidies to low- outpatient mental health services to seek help than African
income families, for those in need to obtain health insurance American women (39%) and non-African American males
coverage and it is estimated that roughly 26 million people (51%).3 Further studies have examined the role of the values

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and belief systems of African American men and their willing- order to improve the state of mental health care for minorities
ness to seek treatment from mental health services available to to bridge the disparity gap considerably.
them. Results from these studies indicated that one potential
barrier to seeking therapy was the perception among African Disclosure
Americans that psychotherapy was associated with weakness The authors report no conflicts of interest in this work.
and diminished pride.3 The notion that seeking treatment for
mental health disorders is perceived as a sign of weakness References
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