Although African American, Hispanic, and White women experience depression at similar rates (Asian women have the lowest rate of depression), African American women's experience with depression is persistent and significantly related to psychological distress and/or stressful life events. Enduring depression can be propelled by unrelenting social injustices and trauma, inadequate annual household incomes, insufficient education, single parenting, and the culture-driven belief that strong Black women show no weakness. Symptoms include feeling sad, hopeless, and like everything is an effort all, most, or some of the time. This suggests that symptoms of depression experienced by African American women aren't only chronic, but also occurring at varying degrees of severity that can potentially lead to suicide.
Several factors have served as barriers to African American women seeking mental health treatment. Historically, medical mistreatment of African Americans within the healthcare system has led to distrust of non-African American healthcare providers. This has laid the groundwork for poor mental health treatment outcomes in African American women. Approaches undertaken to address depression in African American women have widely been ineffective. The persistent severity of socioeconomic stressors and racial bias faced daily by African American women has had a long-standing negative impact on their mental health; however, the stigma associated with having a mental illness or expressing any sign of weakness contributes to African American women not seeking the necessary treatment.
Nursing interventions are grounded in the knowledge that health—physical, mental, social, and spiritual—involves treatment of the whole person, which is fostered through relationship building and acknowledging the culturally specific beliefs, values, and motivations that affect health decisions. This includes addressing the specific biological and physiologic factors and social experiences connected to depression in African American women. Effective treatment for acute episodes and neutralization of the long-term effects of depression among African American women are keys to equity in healthcare outcomes for this vulnerable population. Nurses have an integral role in the delivery of this care.
Depression defined
According to the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, depression or major depressive disorder is characterized as experiencing five or more of the following symptoms:
- depressed mood
- loss of interest in things previously found pleasurable
- weight loss or weight gain
- cognitive impairment
- difficulty concentrating or indecisiveness
- loss of energy or fatigue
- feelings of worthlessness or inappropriate guilt
- thoughts of suicide or recurrent suicidal attempts.
At least one of the symptoms must be depressed mood or loss of interest in things previously found pleasurable. Symptoms must occur during the same 2-week period most of the day, nearly every day. The symptoms can range from mild to severe but must cause the individual significant distress or impairment in social, occupational, or other important areas of functioning.
Precursors of depression
There are several known biological, physiologic, and socioeconomic precursors of depression. Each precursor coincides with social/personal factors, exerting a direct effect on the individual's well-being. It's suggested that the higher prevalence of depression in women is driven by the disproportionate expression of each of these factors. Although depression runs in families, individuals with a genetic predisposition for developing depression may only become symptomatic if exposed to persistent environmental stress.
Obesity
Genes associated with obesity are located in the same region as those that regulate mood, which could be evidence of a causal relationship between obesity and depression. Nearly 80% of African American women are overweight or obese, which puts them at greater risk for depression. These women are also more likely to be subjected to weight discrimination, causing further psychological distress.
Inflammatory proteins are produced by fat cells and promote depression by disrupting serotonin, dopamine, glutamate, and norepinephrine. This interaction leads to chronic hyper release of cortisol. Sustained release of cortisol inhibits release of serotonin in the brain, which results in decreased levels of the chemicals necessary for immunity. In addition, when cortisol levels remain high, there's an increased craving for the high-fat, high-calorie foods that cause obesity.
Women typically exhibit more of an inflammatory response to depression as compared with men. This is largely due to a higher sensitivity to inflammation's behavioral effects. Inflammation induces symptoms of depression, such as loneliness and withdrawal, and risk factors for depression, such as childhood stressors, relationship stress, obesity, and physical inactivity, contribute to elevations in inflammation. Obesity and physical inactivity independent of each other foster greater levels of inflammation and, therefore, symptoms of depression.
Dietary considerations
Women are more likely than men to be emotional eaters—eating during times of stress as a method of coping—which may be associated with higher rates of depression. It has also been suggested that stress is a primary trigger for emotional eating in women. Research studies have shown that when negative emotions are high, intake of healthy food choices is overshadowed by the desire to alleviate the negative emotions. Because of the chronic stress seen in African American women, increased cortisol levels can lead to poor food choices, overeating, and a high body mass index.
For individuals who reside in impoverished communities, high-fat fast foods are easily accessible and there are fewer supermarkets that supply fresh fruits and vegetables. Within these obesogenic environments, unhealthy food is affordable and in abundance whereas healthy food is expensive and scarce.
In addition, African American women have decreased vitamin D intake, which contributes to depression. Individuals with darker skin absorb less sunlight due to hyperpigmentation; therefore, sunlight is ineffective for production of sufficient levels of vitamin D without long-term exposure. Vitamin D is also gained from dietary intake, primarily in the form of dairy products; however, more than 70% of African Americans are lactose intolerant, so dairy is eliminated from the diet. Vitamin D insufficiency then becomes chronic and may play a role in the persistent symptoms of depression experienced by African American women.
Physical activity levels
Individuals who don't participate in regular physical activity are at greater risk for depression. Beneficial physiologic and psychological changes occur with routine physical activity, such as the release of dopamine, serotonin, and endorphins, which are associated with reward, pleasure, and happiness and directly correlated with improved sleep and decreased anxiety. Dopamine, serotonin, and endorphins are also known to reduce cortisol release and mitigate stress levels. Even in small increments (10-minute bouts), physical activity can improve mood and reduce stress levels as it lowers body weight.
The inability to overcome barriers to physical activity has increasingly led to higher rates of overweight/obesity in African American women. These barriers are multifactorial and require interventions that address each simultaneously. For example, barriers for African American women are similar to all women, including lack of time, fatigue, competing family and occupational responsibilities, and associated costs such as purchasing a gym membership. One barrier specific to African American women is hair care and maintenance. Healthy, well-maintained hair is a sign of beauty and pride for many African American women; however, the costs associated with hair care and maintenance adds to other household costs, such as transportation and childcare, which may not leave room in the budget for a gym membership.
Socioeconomic factors
Higher rates of depression are associated with the effects of low socioeconomic status, having less than a high-school diploma, being female and single, and facing racial and gender discrimination. Socioeconomic disparities in the African American community limit necessary resources in education, employment, and healthcare access, which contributes to poor mental health. When coupled with genetic predisposition, overweight/obesity, poor diet, and physical inactivity, these socioeconomic factors can bring about more severe and persistent symptoms of depression.
Best-practice recommendations
Treatment and management of depression in African American women are best approached from several different pathways. Nurses in all settings (inpatient, community, and private practice) can advocate for their patients through screening, pharmacologic treatment, lifestyle modifications, and supportive resources that are culturally specific and compassionate.
Screening
Depression screening should be made routine for African American women. Daily stressors that have become a normal part of life indicate the need for routine depression screenings despite the stated reason for the healthcare visit. If your female patient is overweight/obese and/or positive for metabolic syndrome, screen for depression because of the relationship between depression and increased weight.
Pharmacologic treatment
Antidepressants are the first line of treatment for depression. Vitamin D supplementation is a low-cost alternative that can be used alone to reduce depression symptoms or in combination with antidepressants. Educate your patient about the possible adverse reactions associated with antidepressants, including the potential for increased depression symptoms in the beginning of therapy, and the negative effects of abrupt discontinuation. Before starting an antidepressant, inform your patient that medications for chronic illnesses, such as beta-blockers and calcium channel blockers used to treat metabolic syndrome, may also cause feelings of low mood or sadness.
Psychotherapy
Medication therapy in combination with psychotherapy is the most effective treatment for depression. From an early age, African American women are taught to show strength despite daily traumas. This is practiced as an extension of the need to self-protect and for protection of the family. Therapists must have knowledge and understanding of these pervasive traumas when tailoring psychotherapeutic treatment for African American women. Be mindful of connecting your patient with a female therapist of color; one online resource is www.blackfemaletherapists.com.
Diet and physical activity
African American women should receive education on good dietary habits and the amount and type of exercise necessary for positive health benefits. A balanced diet includes diverse nonstarchy vegetables and fruits (preferably fresh) and is low in animal fat and refined sugars. Community centers, urban farms, and food pantries can be resources to obtain fresh fruits and vegetables. Instruct your patient to engage in a minimum of 30 minutes of moderate-intensity exercise at least 5 days a week. Walking is an excellent way to achieve the recommended physical activity goals. Be mindful that safety is an issue in many communities of color. Recommend connection with and/or development of community walking groups or incorporating physical activity into a family routine that can be carried out together.
Social support
Inquire about sources of stress and readily available sources of social support. We must also educate African American women that support can come from significant others, family members, friends, members of their religious community, and other community members. Inform your patient about additional sources of support, such as joining an in-person or virtual support group to address the traumatic experience of being African American and female. Spirituality is integral to many African Americans; therefore, assessment of spiritual practices should also be explored as a potential strategy for alleviating depression.
Cultural competency training
Because of the impact of culture on health outcomes, cultural competency training is paramount to understanding the lived experience of African Americans. Such training should be provided by employers and nursing educators. As lifelong learners, nurses should seek out continuing-education experiences that increase their awareness of other cultures.
Research shows that African Americans are more likely to openly share their symptoms and feelings with someone who resembles them. African American healthcare workers should be equally represented in the healthcare arena because their very presence can positively affect health outcomes and eliminate health disparities.
Compassionate care
Nurses should lead with compassionate care, particularly for those patients experiencing numerous and unrelenting health and social issues. African American women are at high risk for premature mortality due to chronic illness and disease, face daily racial and gender discrimination and, in many instances, are single mothers at or near the poverty level. Compassionate care is evident when the nurse is genuinely concerned for their patient's well-being. The intentional act of giving additional time to listen to the patient's concerns helps alleviate suffering and makes it possible to develop a relationship that serves as a safe place for the patient.
Research shows that compassionate care isn't consistently extended to African Americans, which means relationship building doesn't always occur. It's necessary then to approach the care of African American women through genuine, compassionate interactions in which the patient feels respected, understood, and that her feelings and concerns are acknowledged and validated by the nurse. It may take an extended period of time to develop this relationship; however, don't let one failed attempt deter you.
Personalize for positive outcomes
African American women live with persistent stress that results in physical wear and tear that for some is irreversible. This damage increasingly causes chronic physical and mental disease states and premature, preventable deaths. The factors discussed in this article should be of primary concern for nurses, leading to the personalized treatment and management of depression in African American women.
on the web
Anxiety and Depression Association of America:
https://adaa.org/learn-from-us/from-the-experts/blog-posts/consumer/be-female-anxious-and-black
Black Women's Health Imperative:
https://bwhi.org/2017/07/31/depression-black-women-know-youre-depressed
Johns Hopkins Medicine:
www.hopkinsmedicine.org/health/wellness-and-prevention/mental-health-among-african-american-women
Mental Health America:
www.mhanational.org/issues/black-and-african-american-communities-and-mental-health
National Alliance on Mental Illness:
www.nami.org/find-support/diverse-communities/african-americans
Office of Minority Health:
www.minorityhealth.hhs.gov
REFERENCES
Aagard M, Papadopoulos I, Biles J. Exploring compassion in U.S. nurses: results from an international research study.
Online J Issues Nurs. 2018;23(1).
Alghamdi S, Alsulami N, Khoja S, Alsufiani H, Tayeb HO, Tarazi FI. Vitamin D supplementation ameliorates severity of major depressive disorder.
J Mol Neurosci. 2020;70(2):230–235.
Allen AM, Thomas MD, Michaels EK, et al. Racial discrimination, educational attainment, and biological dysregulation among midlife African American women.
Psychoneuroendocrinology. 2019;99:225–235.
Ames BN, Grant WB, Willett WC. Does the high prevalence of vitamin D deficiency in African Americans contribute to health disparities.
Nutrients. 2021;13(2):499.
Assari S. High income protects Whites but not African Americans against risk of depression.
Healthcare (Basel). 2018;6(2):37.
Assari S. Race, depression, and financial distress in a nationally representative sample of American adults.
Brain Sci. 2019;9(2):29.
Barbour S. These virtual mental health resources for Black Women can make all the difference.
Cosmopolitan. 2020.
www.cosmopolitan.com/health-fitness/a32731463/mental-health-resources-for-black-women.
Bolton D, Gillett G.
The Biopsychosocial Model of Health and Disease: New Philosophical and Scientific Developments. London, England: Palgrave Pivot; 2019.
Brody DJ, Pratt LA, Hughes JP. Prevalence of depression among adults aged 20 and over: United States, 2013-2016. 2018.
www.cdc.gov/nchs/data/databriefs/db303.pdf.
Brown LL, Cohen B, Tabor D, Zappala G, Maruvada P, Coates PM. The vitamin D paradox in Black Americans: a systems-based approach to investigating clinical practice, research, and public health—expert panel meeting report.
BMC Proc. 2018;12(suppl 6):6.
Fluetsch N, Levy C, Tallon L. The relationship of physical activity to mental health: a 2015 behavioral risk factor surveillance system data analysis.
J Affect Disord. 2019;253:96–101.
Hall RR, Francis S, Whitt-Glover M, Loftin-Bell K, Swett K, McMichael AJ. Hair care practices as a barrier to physical activity in African American Women.
JAMA Dermatol. 2013;149(3):310–314.
Holden KB, Bradford LD, Hall SP, Belton AS. Prevalence and correlates of depressive symptoms and resiliency among African American women in a community-based primary health care center.
J Health Care Poor Underserved. 2013;24(4 Suppl):79–93.
Howard DM, Adams MJ, McIntosh AM, et al. Genome-wide meta-analysis of depression identifies 102 independent variants and highlights the importance of the prefrontal brain regions.
Nat Neurosci. 2019;22(3):343–352.
Jokela M, García-Velázquez R, Airaksinen J, Gluschkoff K, Kivimäki M, Rosenström T. Chronic diseases and social risk factors in relation to specific symptoms of depression: evidence from the U.S. national health and nutrition examination surveys.
J Affect Disord. 2019;251:242–247.
Joseph RP, Ainsworth BE, Keller C, Dodgson JE. Barriers to physical activity among African American women: an integrative review of the literature.
Women Health. 2015;55(6):679–699.
Joseph RP, Coe K, Ainsworth BE, Hooker SP, Mathis L, Keller C. Hair as a barrier to physical activity among African American women: a qualitative exploration.
Front Public Health. 2018;5:367.
Kandola A, Ashdown-Franks G, Hendrikse J, Sabiston CM, Stubbs B. Physical activity and depression: towards understanding the antidepressant mechanisms of physical activity.
Neurosci Biobehav Rev. 2019;107:525–539.
Lee MJH, Reddy K, Chowdhury J, et al. Overcoming the legacy of mistrust: African Americans' mistrust of medical profession.
J Healthc Ethnics Adm. 2018;4(1):17–40.
Liao KY, Wei M, Yin M. The misunderstood schema of the strong Black woman: exploring its mental health consequences and coping responses among African American women.
Psychol Women Q. 2019;44(1):84–104.
Lincoln KD. Social stress, obesity, and depression among women: clarifying the role of physical activity.
Ethn Health. 2019;24(6):662–678.
Menon V, Kar SK, Suthar N, Nebhinani N. Vitamin D and depression: a critical appraisal of the evidence and future directions.
Indian J Psychol Med. 2020;42(1):11–21.
Milaneschi Y, Simmons WK, van Rossum EFC, Penninx BW. Depression and obesity: evidence of shared biological mechanisms.
Mol Psychiatry. 2019;24(1):18–33.
National Institutes of Health. Vitamin D: fact sheet for health professionals. 2021.
https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional.
Pickett S, McCoy TP, Odetola L. The influence of chronic stress and emotions on eating behavior patterns and weight among young African American women.
West J Nurs Res. 2020;42(11):894–902.
Tyrrell J, Mulugeta A, Wood AR, et al. Using genetics to understand the causal influence of higher BMI on depression.
Int J Epidemiol. 2019;48(3):834–848.
US Department of Health and Human Services. Physical activity guidelines for Americans, 2nd edition. 2018.
https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf.
Warren BJ. The synergistic influence of life experiences and cultural nuances on development of depression: a cognitive behavioral perspective.
Issues Ment Health Nurs. 2020;41(1):3–6.
Watson NN, Hunter CD. Anxiety and depression among African American women: the costs of strength and negative attitudes toward psychological help-seeking.
Cultur Divers Ethnic Minor Psychol. 2015;21(4):604–612.
