"Depression in African-American women is underrecognized and undertreated." Paying attention to several key cultural issues, however, may help psychiatrists better care for this group of patients, said Allesa English, M.D., an assistant professor of psychiatry at the University of Tennessee, Memphis Center for Health Science and director of its psychiatry residency program.

The actual prevalence of mood disorders in this population is unclear, said English, who spoke in June at a University of Tennessee, Memphis, family medicine/psychiatry continuing medical education program. Data from the five-site Epidemiological Catchment Area survey, published in 1999, said that blacks in general were less likely than whites to have a major depressive episode, major depressive disorder, or dysthymia, but more likely to have phobias or somatization disorders. In 2005, the National Health and Nutrition Examination Study III found lower rates of depressive disorder among African Americans than whites, but said that dysthymia rates were higher. Other studies have found rates of depression similar to those of whites, and at least one reported that U.S.-born, African-American women were three times more likely to have "probable depression" than black women immigrants from Africa or the Caribbean, she said.

"Often African-American women present differently," said English. "They may not use words liked 'depressed' or 'sad' but rather complain that they are tired or have nonspecific back pain."

Both presentation and clinical care are affected by the cultural milieu in which many black American women live, said English.

"They may not seek treatment for depression because they are unaware they have it, or because of stigma or lack of access," she said.

Many African-American women have trouble recognizing depression as a disease, she said. Those who grew up in households with a person who was depressed may see it as a norm and lack an alternative model. Others may idealize the "strong black woman," the pillar of her family and community, who says, "I can handle it," and can't let anyone think she is weak.

Furthermore, living with discrimination as a member of a minority group induces a double stigma and resistance to diagnosis, said English. "She may think: 'I'm already black. Do I have to be crazy too?'"

At the same time, numerous barriers may interfere with diagnosis and treatment. Many black women may be unfamiliar with the complexities of the health care system and don't know where to start. There may be few mental health clinicians in their communities or they may find it hard to schedule regular appointments because of work or family commitments. When they do see a doctor, clinical time spent on comorbid general medical problems may limit opportunities to discuss depression.

Relationships between African-American women and their doctors may also be problematic. English cited research associating depression with" difficulty in talking to physicians, likelihood of discussing problems with physicians, reporting that a physician had made offensive comments, and the likelihood of changing physicians due to dissatisfaction."

Religion and spirituality play an important role in lives and health of black women, said English. A 2003 survey of 99 African-American pastors found that while 62 percent saw a biological basis for mental illness, the same proportion listed "stunted spiritual growth or unconfessed sin" as contributing factors. In that same survey, only 25 percent of the pastors said they had ever referred parishioners to a mental health care clinician.

Even when depression is diagnosed, many African-American women resist taking antidepressant medications, out of a general distrust of the medical community or because they fear side effects and drug dependence, she said.

Using medications also represents an acknowledgement of the severity of their illness. "They feel that if they are taking a pill, then their condition is really bad and implies that they are giving up on God and the church as sources of support," said English.

Primary care providers can improve depression outcomes for African-American women by integrating mental health services with general medical care, ideally by including to their office staff someone who specializes in mental health.

When prescribing antidepressant medications, clinicians should consider different rates of drug metabolism in people of African descent compared with Caucasian populations due to gender and ethnic variations in the cytochrome P450 system and other metabolic pathways, said English.

"Psychiatrists should also find ways to educate the community in general and the African-American clergy in particular," she said. Her department has begun a cooperative educational program with one large church in the community. Family or couples therapy or support groups may also provide alternative entries into the mental health system. "When we're dealing with women, we're dealing with families."

Finally, the recognition and treatment of depression among African-American women would benefit from increased research into the phenomenology of depressive symptoms in this population group, differences in their response to antidepressants, and ways of decreasing stigma and increasing access to mental health care, she stated. ▪