Mark Moran Fervently held religious beliefs in the African-American communitythat prayer—and prayer alone—can heal distress anddisease may serve as a barrier to recognition and effectivetreatment of depression.
"As a spiritual man, I look to God. But you know what God isgoing to do? He's going to send you to a doctor."
—-from"Black and Blue," a videotape about the stigma of depressionin the African-American community
Stigma about mental illness and depression is compounded forblack Americans by social and cultural factors unique to theAfrican-American experience, said Annelle Primm, M.D., M.P.H.,at a meeting of the Black Psychiatrists of America in KansasCity, Mo.
Primm joined the APA staff in late April as director of itsDepartment of Minority and National Affairs. Formerly she wasan associate professor of psychiatry and behavioral sciencesat the Johns Hopkins University School of Medicine.
In her presentation, "Major Depression: Stigma and Myth," Primm saidthese factors include the pre-existing stigma associated withbeing a person of color, certain fervently held religious beliefs,distrust of the medical profession, and language and literacybarriers to appropriate care.
"All of these have an impact on efficacy of treatment, patient adherence,and the development of an effective partnership [with a physician], whichwe know has a major impact on outcome in terms of morbidityand mortality, well-being, and functioning," Primm said.
She outlined the disparities in health care that affect AfricanAmericans, noting that though depression is "an equal opportunitydisorder" with similar prevalence rates among blacks and whites,African Americans are far less likely to receive a diagnosis.
They are likely to have poorer health status and a disproportionateshare of uninsurance. Primm noted as well that suicide ratesfor African-American males between the ages of 18 and 24 roseprecipitously in the last decade.
"This was a real wake-up call to the public health communitythat suicide does occur in the black community," she said. "Buteven when people get in the door of the mental health or generalhealth provider, they are much less likely to get guideline-consistentcare than whites. We have a great deal of education to do atthe provider and the patient level."
Another Stigmatizing Label
Primm said that to increase the recognition, diagnosis, andtreatment of depression among black Americans, public healthefforts must be targeted at some of the barriers to care thatare specific to African Americans.
Prominent among these is the persistence of racism. "Being African Americanin this society and culture itself carries with it a stigma," shesaid. "To add another stigmatizing label is something people understandablywant to avoid."
Primm said the stigma is compounded by a mistrust of healthprofessionals, with historical events such as the Tuskegee projectlending credence to those concerns.
(The Tuskegee Syphilis Study was a four-decade, prospectiveresearch project of the U.S. Public Health Service designedto study the effects of untreated syphilis among African-Americanmen in the south. The project, which involved the active, unethicaldenial of treatment to the subjects, ended in 1972.)
Also impeding treatment of depression is a pervasive and ferventlyheld religious belief that prayer—and prayer alone—canheal distress and disease.
Moreover, the legacy of suffering in African-American life hasin some ways come to be taken as a given. "Many people believethat suffering is a part of life for African Americans, so theyshould just `keep on keeping on,' no matter how burdened theyare or how much suffering they are enduring," Primm said.
She drew attention to the "pathoplasticity" of depression—theunique way it expresses itself within a specific cultural context.For African Americans, depression is liable to express itselfin one of three culturally iconic ways: the "stoic believer,"who relies on the power of prayer; the "John Henry doer," whosehigh level of functioning belies a deep depression; and the"angry, evil one."
The last of these, particularly, is often a pathway that leadsnot to treatment, but to arrest and incarceration, Primm said.
Better Screening Needed
Primm said problems around stigma associated with depressionin African Americans call for more aggressive secondary-preventionefforts to screen for the disorder.
She cited several success stories, including the Community Academic CollaborationProject. That project involved recruiting minority groups in Baltimoreand Pittsburgh and educating nonprofessionals on how to conduct healthscreening, with a focus on screening for depression. The project effectivelyscreened 600 individuals across the two sites, Primm said.
Primm also showed conference participants a 16-minute videotapeshe developed titled "Black and Blue." The video is a culturally tailorededucational tool with testimony from African Americans who havebeen treated for depression.
The tape addresses many of the myths about depression and treatment outlinedby Primm, with a special focus on religious and spiritual beliefs thatcan act as a barrier to seeking treatment. The video includedtestimony from an African-American pastor and patient who said,"As a spiritual man, I look to God. But you know what God isgoing to do? He's going to send you to a doctor."
The tape has been evaluated with a 20-item questionnaire administeredto viewers before and after the showing. Primm said the videosignificantly changed attitudes among respondents about depression,including attitudes about the efficacy of prayer alone and aboutthe benefits of medication.
People interested in purchasing a copy of "Black and Blue" shouldsend a check or money order for $35 (includes shipping and handling)to Blue Rock Productions, 4226 Amos Avenue, Baltimore, Md. 21215. Purchasersare requested to specify the nine-minute or 16-minute version,as well as preferred format: VHS, CD-ROM, or DVD.