Annelle Primm, M.D.: "Many people believe that suffering is a part
of life for African Americans, so they should just 'keep on keeping
Stigma about mental illness and depression is compounded for black
Americans by social and cultural factors unique to the African-American
experience, said Annelle Primm, M.D., M.P.H., at a meeting of the Black
Psychiatrists of America in Kansas City, Mo.
Primm joined the APA staff in late April as director of its Department of
Minority and National Affairs. Formerly she was an associate professor of
psychiatry and behavioral sciences at the Johns Hopkins University School of
In her presentation, "Major Depression: Stigma and Myth," Primm
said these factors include the pre-existing stigma associated with being a
person of color, certain fervently held religious beliefs, distrust of the
medical profession, and language and literacy barriers to appropriate
"All of these have an impact on efficacy of treatment, patient
adherence, and the development of an effective partnership [with a physician],
which we know has a major impact on outcome in terms of morbidity and
mortality, well-being, and functioning," Primm said.
She outlined the disparities in health care that affect African Americans,
noting that though depression is "an equal opportunity disorder"
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 disproportionate share
of uninsurance. Primm noted as well that suicide rates for African-American
males between the ages of 18 and 24 rose precipitously in the last decade.
"This was a real wake-up call to the public health community that
suicide does occur in the black community," she said. "But even
when people get in the door of the mental health or general health provider,
they are much less likely to get guideline-consistent care than whites. We
have a great deal of education to do at the provider and the patient
Primm said that to increase the recognition, diagnosis, and treatment of
depression among black Americans, public health efforts must be targeted at
some of the barriers to care that are specific to African Americans.
Prominent among these is the persistence of racism. "Being African
American in this society and culture itself carries with it a stigma,"
she said. "To add another stigmatizing label is something people
understandably want to avoid."
Primm said the stigma is compounded by a mistrust of health professionals,
with historical events such as the Tuskegee project lending credence to those
(The Tuskegee Syphilis Study was a four-decade, prospective research
project of the U.S. Public Health Service designed to study the effects of
untreated syphilis among African-American men in the south. The project, which
involved the active, unethical denial of treatment to the subjects, ended in
Also impeding treatment of depression is a pervasive and fervently held
religious belief that prayer—and prayer alone—can heal distress
Moreover, the legacy of suffering in African-American life has in some ways
come to be taken as a given. "Many people believe that suffering is a
part of life for African Americans, so they should just `keep on keeping on,'
no matter how burdened they are or how much suffering they are
enduring," Primm said.
She drew attention to the "pathoplasticity" of
depression—the unique way it expresses itself within a specific cultural
context. For African Americans, depression is liable to express itself in one
of three culturally iconic ways: the "stoic believer," who relies
on the power of prayer; the "John Henry doer," whose high level of
functioning belies a deep depression; and the "angry, evil
The last of these, particularly, is often a pathway that leads not to
treatment, but to arrest and incarceration, Primm said.
Primm said problems around stigma associated with depression in African
Americans call for more aggressive secondary-prevention efforts to screen for
She cited several success stories, including the Community Academic
Collaboration Project. That project involved recruiting minority groups in
Baltimore and Pittsburgh and educating nonprofessionals on how to conduct
health screening, with a focus on screening for depression. The project
effectively screened 600 individuals across the two sites, Primm said.
Primm also showed conference participants a 16-minute videotape she
developed titled "Black and Blue." The video is a culturally
tailored educational tool with testimony from African Americans who have been
treated for depression.
The tape addresses many of the myths about depression and treatment
outlined by Primm, with a special focus on religious and spiritual beliefs
that can act as a barrier to seeking treatment. The video included testimony
from an African-American pastor and patient who said, "As a spiritual
man, I look to God. But you know what God is going to do? He's going to send
you to a doctor."
The tape has been evaluated with a 20-item questionnaire administered to
viewers before and after the showing. Primm said the video significantly
changed attitudes among respondents about depression, including attitudes
about the efficacy of prayer alone and about the benefits of medication.
People interested in purchasing a copy of "Black and
Blue" should send a check or money order for $35 (includes shipping and
handling) to Blue Rock Productions, 4226 Amos Avenue, Baltimore, Md. 21215.
Purchasers are requested to specify the nine-minute or 16-minute version, as
well as preferred format: VHS, CD-ROM, or DVD. ▪