Depression is a huge health concern among African-Americans -- particularly women -- but mental health is often stigmatized in the black community. Although it can impact people from all walks of life, cultural habits and historical experiences can cause depression to be expressed and addressed differently among black women.

"During slavery, you were supposed to be the strong one. You weren't supposed to speak. You were supposed to just do," said Esney M. Sharpe, founder and CEO of the Bessie Mae Women's Health Center in East Orange, New Jersey, which offers health services for uninsured and underserved women.

Although some figures vary based on the study, depression affects between 17-20 million Americans a year. Data from a study published by the Center for Disease Control -- the CDC -- found that women (4 percent vs. 2.7 percent of men) and African-Americans (4 percent) are significantly more likely to report major depression than whites (3.1 percent).

But the CDC also finds that just 7.6 percent of African-Americans sought treatment for depression compared to 13.6 percent of the general population in 2011.

Because the findings show that women -- regardless of race or ethnicity -- are more likely than men to experience depression, and African-Americans experience major depression at higher rates than whites, then black women in turn also experience high rates of depression compared to the general population.

Despite other studies showing conflicting data that are at odds with these findings, the CDC appears to be more reliable because it is the most recent study of its kind.

A Lack of Treatment

Black women are among the most undertreated groups for depression in the nation, which can have serious consequences on the African-American community.

"I've tried to commit suicide over 15 times. I have the scars on my arms of wanting to kill myself and not even know why," said 45-year-old Tracey Hairston, a member of the health center who has bipolar disorder, a form of depression.

A report published by researchers at the University of Wisconsin found that poverty, parenting, racial and gender discrimination put black women -- particularly low-income black women -- at greater risk for major depressive disorder (MDD).

Depression is not only treated at lower rates in the African-American community, particularly among black women, but of those who do receive treatment, many don't receive adequate treatment.

Hector M. Gonzalez, Ph.D., and colleagues at Wayne State University, Detroit, found that overall, only about half of Americans diagnosed with major depression in a given year receive treatment for it. But only one-fifth receive treatment consistent with current practice guidelines. African-Americans had some of the lowest rates of use of depression care.

Because blacks, particularly black women, experience higher rates of depression than their white female or black male counterparts, but receive lower rates of treatment for depression -- specifically adequate treatment -- they remain one of the most undertreated groups for depression in the United States. Several major reasons account for high rates of depression and low rates of treatment for depression among African-American women.

Lack of Health Insurance

A lack of adequate health care can significantly contribute to low rates of the treatment of depression among African-Americans, particularly African-American women. More than 20 percent of black Americans are uninsured compared to less than 12 percent of whites.

Diane R. Brown is a professor of health education of behavioral science at the Rutgers School of Public Health and co-author of, "In and Out of Our Right Minds: The Mental Health of African-American Women." Her research shows a correlation between socioeconomic status and poor physical and mental health.

"There's a strong relationship between socioeconomic status and health such that people at the lower end, people in poverty tend to have poorer health and tend to have fewer resources ... for dealing with the stressors of life," Brown said.

According to the National Poverty Center, poverty rates for blacks greatly exceed the national average. And poverty rates are highest for families headed by single women, particularly if they are black or Hispanic.

Studies show about 72 percent of black mothers are single compared to 29 percent for non-Hispanic whites, 53 percent for Hispanics, 66 percent for American Indian/Alaska native and 17 percent for Asian/Pacific Islander.

Since black women are more likely to be poor, to be unmarried and to parent a child alone, which are all stressors that can contribute to poor mental health, they are also least likely to have resources like adequate mental health insurance to address problems such as depression.

Shame and Embarrassment

Because mental health is a taboo subject in the African-American community, black people, and specifically black women, are not only one of the least likely groups to be treated or to seek treatment for depression, they're also less likely than other groups to even acknowledge it as a serious problem because of the shame and embarrassment that it can cause.

Psychologist Lisa Orbe-Austin, who runs a practice with her husband and treats predominantly black women, said her patients often struggle with distorted images of themselves because of the mischaracterizations they face daily.

She said psychologists treating black women often "try to help them shed some of these stereotypical experiences to kind of cope with healthier ways and to try to find a more integrated sense of self where they feel like they're truly authentically themselves."

Depression can effect anyone but cultural and gender differences cause depression to be experienced and expressed differently in African-American woman compared to other subgroups of the population. These cultural and gender differences have a major impact on whether and how black women are treated for depression.

Researchers at the National Alliance for Mental Illness (NAMI) find that "African-American women tend to reference emotions related to depression as 'evil' or 'acting out.'"

They cite research providing evidence of communities holding on to long legacies of secrets, lies and shame originating from slavery. Avoiding emotions was a survival technique, which has now become a cultural habit for African-Americans and a significant barrier to treatment for depression.

As a result black women are more likely to deal with the shame many feel about poor mental health and depression in much of the same way by avoiding the emotional toll it takes on them.

Lack of Knowledge

Because of negative stigmas surrounding mental health and depression, there is an extreme lack of knowledge about depression in African-American communities.

Researchers at Mental Health America find that African-Americans are more likely to believe depression is "normal." In fact, in a study commissioned by Mental Health America on depression, 56 percent of blacks believed that depression was a normal part of aging.

A report published by the National Institute of Health (NIH) examined black women's representations and beliefs about mental illness. Researchers cite the low use of mental health services by African-American women and identify stigma as the most significant barrier to seeking mental health services among blacks.

Not only do a troubling number of African-Americans not understand depression to be a serious medical condition, but the stereotype of the strong black woman leads many African-American women to believe that they don't have the luxury or time to experience depression. Some even believe it is only something White people experience.

"When seeking help means showing unacceptable weakness, actual black women, unlike their mythical counterpart, face depression, anxiety, and loneliness," writes author Melissa Harris-Perry in her book "Sister Citizen: Shame, Stereotypes, and Black Women in America."

"Through the ideal of the strong black woman, African-American women are subject not only to historically rooted racist and sexist characterizations of black women as a group but also a matrix of unrealistic interracial expectations that construct black women as unshakeable, unassailable and naturally strong."

African-Americans tend to cope with mental health problems by using informal resources like the church, family, friends, neighbors and coworkers. In many cases they seek treatment from ministers and physicians as opposed to mental health professionals.



This form of coping can be beneficial for black women who are uncomfortable with traditional forms of mental health care. But it can also encourage beliefs about negative stigmas surrounding mental health in the black church.

Orbe-Austin said attitudes and beliefs about mental illness and mental health services in the black community tend to lean towards the idea that therapy is not a traditional coping mechanism for blacks.

"Psychotherapy is also somewhat culturally bound," said Orbe-Austin. "It comes from a particular history that is not a black history. Those of us who are culturally competent try to bring in other experiences, other cultural experiences to our work so that we don't do it in this culturally bound way."

The challenge, she said, is educating mental health care practitioners on the cultural beliefs of African-Americans and in turn educating blacks on the medical benefits mental health services can produce.

"You really want someone to get it so that when you're trying to function in healthy ways you don't combat other people's issues as well," she said.

Refusal of Help

One of the greatest barriers to keeping black women from receiving treatment for depression is a history of discrimination and a deep mistrust of health care institutions in the U.S., which can cause black women to refuse help when they need it.

Research shows that African-American women's use of mental health services may also be influenced by barriers including, "poor quality of health care, (limited access to clinicians that are culturally competent), and cultural matching (limited access to work with minority clinicians)."

A history of trauma and victimization experienced by African-Americans has also helped foster a cultural mistrust toward the U.S. health care system. Events like the Tuskegee Experiments are hypothesized to contribute to many black people's negative attitudes about health care.

High levels of cultural mistrust have also been linked to a negative stigma of mental illness in the African-American community. Mental health professionals cite it as another significant barrier to treatment seeking for African-American women.

Hope

Despite the seemingly large challenges black women face with regard to mental health and depression, they have been able to develop alternative coping techniques to deal with various stressors and depression including support systems within families, communities and religious institutions.

"Even though they are facing racism and sexism that they are finding ways to care for themselves and accommodate what they're faced with from external society and largely through a lot of relationships and support systems that they built for themselves among relatives and among friends," said Matthew Johnson, a licensed psychologist in New Jersey and faculty member at John Jay College of Criminal Justice.

"We're seeing a change," said Sharpe, "We now see women have a voice and I think that people are seeing that we are extremely intelligent, smart and that we have the compassion to move and to make things happen a little quicker."

Mental health professionals hope, with more awareness, attitudes about depression among black women will shift even more in a positive direction. "I do think our community could use a lot of healing and I do think there's a lot of potential for psychotherapy in our community," said Orbe-Austin.

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