Challenges to Traditional Clinical Definitions of Depression in Young Black Men

Abstract

Despite high rates of unemployment, incarceration, violence, and suicide experienced by young Black men in America, research conducted in inner-city environments consistently report nonsignificant levels of depression among Black men. The unique history of social exclusion, stereotyping, and discrimination experienced by Black men has significant implications for the accurate assessment of depression. A review of significant historical and current sociological, educational, and legal-justice circumstances that affect the mental health of young Black men is presented. Barriers and limitations to traditional depression assessment and measurement is discussed and followed by recommendations for advancing knowledge of depression in young Black men. Research and practice that seeks to explore and explain sociocultural variances in traditional definitions of depression among young Black men will improve mental health, mental health outreach, and social function in this population.

Young Black men in America experience an alarming incidence of unemployment, poverty, institutionalization, and mortality (Alexander, 2010; Tonry & Melewski, 2008). The lives of young Black men are negatively affected by marginal educational preparation provided in many inner-city primary and secondary schools, which limits their preparation for college or gainful employment (Holzman, 2010). For many, the ever-present financial and social lure of gangs, drugs, and other illegal activities present in most inner-city environments undermine attempts at legitimate achievement (Tonry & Melewski, 2008). As a result of social disadvantage and profiling, young Black men are more likely to be incarcerated than those from any other racial/ethnic group (Alexander, 2010; Holzman, 2010).

Social dynamics surrounding race and class for young Black men in America are further confounded by societal expectations for masculinity. However, an appreciation for historical cultural influences on Black masculinity and family dynamics is necessary for a broad and well-informed perspective today. The moment that European men fully engaged in the African slave trade began the immediate fallout for the African American culture (hooks, 2004). The peaceful nature and interaction of relationships between African men and women would forever be changed by the humiliation, degradation, and oppression of chattel slavery (hooks, 2004). Both enslaved and liberated Black men were indoctrinated into cultures that endorsed respect for marital bonds, material provision for family, and homebound responsibility for women (hooks, 2004). However, these cultural expectations for manhood were and continue to remain elusive for many Black males (hooks, 2004). Circumstances of enslavement, racism, and oppression prevented Black men from maintaining stable marital relations both during and after slavery and from obtaining substantial employment to support their families (hooks, 2004). These gaps between cultural expectations for masculinity and the reality of daily life for Black men propagated much of the psychological conflict that continues to affect Black men today.

Practitioners engaged in therapeutic relationships with young Black males should consider the historical nature of the social issues affecting this population. Culture, age, and gender-related differences affect the definition and the expression of depressive symptoms by young Black men and therefore affect accurate identification of the incidence and measurement of depression in this population (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision [DSM-IV-TR]; American Psychiatric Association, 2000; Sharp & Lipsky, 2002). Therefore, the goals of this article are twofold. The first is to highlight historical aspects of the social and economic, context of the lives of young inner-city Black men in America that are relevant to the experiences and perceptions. The second is to discuss how, given the situational context, current tools for identifying clinical depression may not be useful in diagnosing depression in young inner-city Black men. Understanding possible variations in the assessment of depression, as well as factors that may contribute to these variations will increase the sensitivity and impact of practitioners in their work with this highly vulnerable population.

Socioeconomic Status: Intersections of the Past and Present

Emancipation from slavery in the 19th century did not provide young Black men with access to the industrial explosion of manufacturing jobs during the 20th century (Semmes, 1996). Continuing from the late 1800s until well into the 20th century, many northern White employers for large industrial manufacturers believed that Blacks were suited for agricultural work only, making them unfit for well-paying industrial positions (Kusmar, 1976). In the 1930s and 1940s, a great exodus of Blacks from rural Southern towns to northern industrial cities took place. However, discriminatory practices in hiring limited opportunities for Black men to obtain jobs and wages comparable to those of the larger society (W. J. Wilson, 1997). These practices continued to be documented into the late 1980s; the Urban Poverty and Family Life Survey found that almost 75% of manufacturing employers avoided hiring Black males because of their lack of educational preparedness and professionalism, as well as “their “laziness” and “aggression” (W. J. Wilson, 1997, pp. 118, 125). Decades of race-related, stereotyping and exclusion from well-paying jobs continued to inhibit many young Black men from attaining financial stability and from adequately providing for their families, with a resultant negative impact on their self-sufficiency (hooks, 2004; W. J. Wilson, 1997).

Educational deprivation begins a trajectory toward negative economic and social consequences for young Black boys (Holzman, 2010). Despite the social and educational gains of Brown v. Board of Education of Topeka and the subsequent desegregation of schools in 1954, substantial remnants of inequality continued to negatively affect the ability of inner-city schools to meet the academic needs of poor young Black students (Wraga, 2006). Many inner-city schools faced challenges of educating young Black students as a result of concentrated poverty in student community environments, limited school budgets, and large class sizes (Ahram, Stembridge, Fergus, & Noguera, n.d.). The barriers to a quality education imposed by these challenges lead to persistently low performance and expectations for minority students and poorly functioning school operations (Ahram et al., n.d.). For example, students attending schools with high concentrations of poor Black and Latino students were more likely to have inexperienced or unqualified teachers, decreased access to college preparatory courses, higher teacher turnover, and more remedial courses (Lee, 2004).

Little change has been realized in recent years related to the quality of schools in lower socioeconomic districts. Young Black boys in particular experience minimal opportunities for advancement in primary academic settings. Black male students are often wrongly placed into special education classes as a result of discriminatory policies and receive much harsher penalties, such as expulsion, for similar classroom infractions when compared with their White counterparts (Holzman, 2010). In many Midwestern and Southern states, Black males have high school graduation rates below 50% (Holzman, 2010). Black men older than 18 years represent only 5% of all college students (Lewis, Simon, Uzzell, Horwitz, & Casserly, 2010); and more Black men acquire a high school equivalency diploma while in prison, than graduate from college each year (Boyd, 2007).

The dynamics of urban life shape much of the current interactions between Black men and the larger society. Young Black men disproportionately experience suicide, homicide victimization, and incarceration (Boyd, 2007; Rogers, Rosenblatt, Hummer, & Krueger, 2001). Although historically having lower rates, the suicide rate among young adult Black men has increased twofold since the 1980s (Boyd, 2007). Homicide is the leading cause of death for Black men aged 15 to 24 years, a rate three times higher than all other population subgroups (Paxton, Robinson, Shah, & Schoeny, 2004). Black males 14 to 24 years of age are implicated in a quarter of homicides in the United States (Boyd, 2007). In fact, some theories suggest that many homicides are an alternative form of suicide. Rather than committing suicide by traditional means such as firearm or suffocation, vulnerable and depressed young men may place themselves at increased risk for deadly force by law enforcement or deliberately provoke well-known violent individuals into an act of homicide against them (Willis, Coombs, Cockerham, & Frison, 2002). Although perpetration of homicide increases the incidence of incarceration of young Black males, the national representation of this population in institutions is drastically disparate with regard to their relative proportion of the total society. Black men represent 40% of the more than 2 million men imprisoned in the United States despite comprising little more than 6% of the total population (McKinnon & Bennett, 2005; West, 2010). Black men aged 18 to 24 years are more likely to be incarcerated than all other men in this age group (Sum, Khatiwada, McLaughlin, & Tobar, 2008). On any day in 2005, at least one third of Black men aged 20 to 29 years were either imprisoned or jailed or on probation or parole (Tonry & Melewski, 2008). Yet despite a decrease in crime rates since 2005, rates of incarceration among young Black men have unexpected and unexplainably increased (Alexander, 2010). Despite recent national trends of bidirectional fluctuations in the overall incidence of crime, the rate of incarceration of young Black men has consistently increased fourfold (Alexander, 2010). The source of the steady increase in conviction and imprisonment of young Black men is rooted in nonviolent crimes related to drug offenses (Alexander, 2010). However, Black men are no more likely to engage in drug use or distribution than Whites (Alexander, 2010). A 2000 study conducted by the National Institute on Drug Abuse found that White students used crack-cocaine at a rate 8 times that of their Black counterparts.

One cause for disparity in incarceration of young Black men for drug-related offenses is that they are more likely to perpetrate drug deals in public and semipublic environments and with strangers, as opposed to White men who typically conduct drug deals behind closed doors with people they know and trust (Tonry & Melewski, 2008). Thus, the ease and likelihood of arrest and subsequent conviction of greater numbers of Black men than White men is increased (Tonry & Melewski, 2008). Finally, increased severity of sentencing for drug-related offenses has also significantly contributed to disparities of imprisonment for Black men. For example, the 1986 federal law known as the “100-to-one law” for crack/powder cocaine sentencing mandates a 5-year prison sentence for possession of 5 grams of crack in contrast to possession of 500 grams of powder cocaine for the same sentence (National Association for the Advancement of Colored People, n.d.). The result of such a law is that small-scale crack cocaine users are punished more severely than the typical more affluent powder cocaine users and their suppliers (National Association for the Advancement of Colored People, n.d.); and thus Blacks are disparately affected by this law.

The consequences of conviction extend far beyond prison walls. One such consequence is higher unemployment among men who have been incarcerated; they are seldom able to attain the employment status and earnings that they had the year prior to incarceration (Boyd, 2007; Waldfogel, 1994; Winnick & Bodkin, 2009). Accordingly, the higher incidence of incarceration for Black males may be one factor that has affected the current Black male unemployment rate of 12.7% (Apel & Sweeten, 2010; U.S. Bureau of Labor Statistics, 2012). A lesser known consequence of incarceration is that a past felony conviction results in permanent loss of voting privileges in 12 states and legally justified discrimination from future housing, education, and professional licensing opportunities (Alexander, 2010; Procon.org, 2012).

Regardless of whether Black men are the perpetrators or are the victims of violence, a disruption of individual and family socioeconomic functioning results (Rogers et al., 2001). Evidence of family disruption is demonstrated by the finding that only 13% of Black children live in households with married parents and 17% live with their mothers only, a rate higher than all other race groups (Lofquist, Lugaila, O’Connell, & Feliz, 2012). Additional struggles associated with food insecurity, crowded living conditions, and lack of medical care compound the lives of half of all Black families today (Sherman, 2006). Children in such economically limited, single-parent families have an exponentially increased risk of having the poverty passed on to their children, or “generational poverty” (Hymowitz, 2005).

Black men residing in the inner city experience significant socioeconomic disparities, excessive targeting by law enforcement, and significantly increased mortality associated with their neighborhoods (Alexander, 2010; Paxton et al., 2004). These experiences are not without significant psychological and/or physiological consequence for this population. Thus, it is essential for health care providers to be knowledgeable of young Black males’ unique cultural expressions and interpretations of depression.

Depression and Assessment Barriers

Depression is a mood disorder characterized by lack of interest or pleasure in most activities and may include a wide array of symptoms including but not limited to effects on appetite, complaints of pain, and feelings of hopelessness and/or helplessness (American Psychiatric Association, 2000). Causes for depression include genetic and hormone imbalances, situational crises, and/or environmental stressors (American Psychiatric Association, 2000; Matheson et al., 2006). Depression is reported to be one of the top causes of disability and loss of productivity in developed countries such as the United States (Smith & Bielecky, 2012). Variations in depression symptom expression exist across culture, ethnicity, and gender. Furthermore, inner-city areas of concentrated poverty, where a large proportion of young Black men reside, possess characteristics of a psychologically hostile environment (American Psychiatric Association, 2000; Latkin & Curry, 2003; Matheson et al., 2006; Paxton et al., 2004; Sharp & Lipsky, 2002). Such environments impose high unemployment, insufficient school systems, violence, and limited housing opportunities. This persistent variety of external sources of stress poses a threat to the psychological and physiological health of young Black men. Stress-related mental and chronic diseases such as depression, anxiety, hypertension, and cardiovascular disease occur more frequently among minorities and individuals living in urban environments (Galea, Ahern, Rudenstine, Wallace, & Vlahov, 2005; Gary, Stark, & LaVeist, 2007; Schulz et al., 2000; Taylor & Turner, 2002).

Although health care providers see the consequences of the physical impact of such stress, they might also anticipate a high rate of discouragement and depression among Black men and women. However, traditional screening tools used in epidemiological research for the assessment of depression in inner-city environments have not found this to be the case. Barriers to assessment of depression and the uniqueness of depression in men are being increasingly recognized and studied (Branney & White, 2008; Brownhill, Wilhelm, Barclay, & Schmied, 2005; Rochlen et al., 2010). However, there is scant literature concerning gender, race, class, and culture impact on incidence, expression, and perception of depression, in young Black men (Epstein et al., 2010; Kendrick, Anderson, & Moore, 2007; Watkins & Neighbors, 2007). Thus, potential depression assessment barriers should be carefully considered when engaging with populations of young Black men who are at risk, namely those in socioeconomically depressed inner-city environments.

Race and class have been reported to found to confound the relationship between gender and depression. Studies of neighborhood effects on mental health found that, in addition to being female, Whites residing in high-poverty urban neighborhoods reported higher psychological distress, depression, and anxiety than Black residents in the same community (Gary et al., 2007; Schulz et al., 2000). A possible explanation for the difference was that Blacks develop more effective psychological coping strategies because of earlier and more frequent exposure to hostile environments (Schulz et al., 2000). This suggestion disregards the impact of these environments on the long-term psychological, physiological, and socioeconomic success, or lack thereof, of young inner-city Black males. Statistical characterizations of young Black men with regard to mortality, education, employment, and legal institutionalization betray assertions of effective psychological coping strategies among the population. Although scholars have long recognized problems with depression measures with regard to cultural sensitivity (Kim, 2010) the efficacy of depression measurement in Blacks and men is seldom scrutinized in large-scale epidemiological urban-based studies.

A significant barrier to the accurate assessment of depression in young Black men is restrictive emotionality, the concealing of emotions in the face of psychological distress which is a common phenomenon among all men (Rochlen et al., 2010; Watkins & Neighbors, 2007). In a study of the meaning of mental health, one young Black man stated “I think everybody has done something to cover up their depression. Nobody wants to walk around showing that type of emotion on their sleeve” (Watkins & Neighbors, 2007, p. 276). Emotional responses such as crying and feelings of loneliness, sadness, and fear are commonly associated with feminine expression of depressive symptoms (Branney & White, 2008). In additional, it has been documented that the Center for Epidemiologic Studies–Depression Scale (CES-D) and other similar DSM criteria–based screening tools are based on emotion-focused criteria, which are more common among women than men (Branney & White, 2008). Rather, men are found to demonstrate greater risk-taking behaviors including deliberate self-harm, anger, drug and alcohol abuse; all of which are nondiagnostic criteria for depression (Branney & White, 2008; Brownhill et al., 2005). A discrepancy exists between outward and more physical displays of depression and the predominately used emotion-focused assessment strategies. This limitation impedes accurate detection of depression in men and may contribute to the low incidence of depression in epidemiological reports (Branney & White, 2008).

Another unique nuance and confounding factor for rejection of outward displays of emotion is that of generalized acceptance of depressed feelings among young Black men or the view that it is “a fact of life” (Kendrick et al., 2007; Watkins & Neighbors, 2007). For many, depression is not a possibility given the daily nature of assaults of racism and discrimination (Watkins & Neighbors, 2007). A focus group study on perceptions of depression in young Black men identified depression as a fact of life (Kendrick et al., 2007). One young Black man stated,

Yeah, you do learn to deal. And because of what we’ve been through in our lives; I feel that our coping mechanism kicks in a lot earlier. I think that’s where the discrepancy may be. Because then somebody will say . . . “I think he may be depressed.” I’ll say I’m not depressed. (Kendrick et al., 2007, p. 70)

It is possible that traditionally constructed definitions and diagnostic criteria of depression may not adequately capture the experiences of young Black males. Interviews with young Black males reveal perceptions that traditional conceptualizations are incongruent with their own beliefs about how depression is experienced and expressed (Kendrick et al., 2007). For example, one young man reported that the standards for depression are different for young Black men because

You don’t have time to be sad, because you have too much to worry about. You’re supposed to be the Black man, take care of everything. You can be depressed but not have the symptoms of depression that a normal person would [have] . . . (Watkins & Neighbors, 2007, p. 276)

One final and notable barrier to identification of depression in young Black men is the stigma associated with mental illness, prevalent in the Black community (Cooper et al., 2003; Hines-Martin, 2002; D. W. Wilson, 2010). A study that examined relationships among stigma, depression, and treatment in a diverse sample found greater mean mental health stigma scores among African Americans (Menke & Flynn, 2009). Stigma associated with mental illness and accompanying feelings of shame and secrecy negatively affect treatment-seeking behaviors and thus arriving at an accurate incidence of depression occurrence is hindered (Menke & Flynn, 2009).

The contradiction between life in an oppressive environment and low rates of depression found when screening Black men leads to the following questions: Do traditional screening tools accurately assess depression in young Black men? What are the indications that young Black men experience depression? How do young Black men experience and manifest depression?

Depression Measurement

The most recently published version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) identifies that gender and cultural variations may contribute to the under and misdiagnosis of depression across populations. However, the manual lacks discussion of cultural variations in depression symptomatology for Blacks and/or males despite inclusion of Asian, Latino, and Middle Eastern cultural differences in depression experiences (American Psychiatric Association, 2000). Furthermore, risks for depression associated with female gender receive considerable attention in the manual, occurring at a 2:1 ratio (American Psychiatric Association, 2000). In many large epidemiological studies of depression in inner-city environments, the incidence of depression was reported to be lower in men than women and also the overall risk for depression was considerably lower for men residing in these areas of the country (Curry, Latkin, & Davey-Rothwell, 2008; Latkin & Curry, 2003; Matheson et al., 2006; Silver, Mulvey, & Swanson, 2002). Limitations in psychometric validity were undocumented in these studies likely because of the expected confirmation of the association of depression with female gender.

The DSM also provides no discussion of the impact of socioeconomic status, despite its well-established inverse relationship with depression (Gary et al., 2007; Latkin & Curry, 2003; Schulz et al., 2000). Many large-scale investigations of depression and related social variables in inner-city environments use measures of depression based on the diagnostic criteria included in the DSM (Curry et al., 2008; Latkin & Curry, 2003; Matheson et al., 2006; Silver et al., 2002). The lack of inclusion of critical influences of socioeconomic status on depression by institutions that determine criteria for diagnosis suggests a need for increased scrutiny of the cultural sensitivity of depression-screening instruments. This is especially important when screening for depression in economically challenged communities.

The CES-D is a self-report survey used to measure depression symptom severity in community populations. Developed in 1977, the CES-D was reported to have high reliability and validity in diverse populations, at the time (Radloff, 1977). The CES-D measures four constructs of depression including depressive affect, positive affect, somatic symptoms, and interpersonal distress (Love & Love, 2006). There is scant literature to support the relevance for widespread use of this screening measure, and others like it, in young Black men. Yet it is the used in the majority of large-scale inner-city studies that would dictate allocation of resources for mental health needs in the most economically depressed areas of the country. To further validate this premise, a recent study that examined reliability and validity of the measure found inconsistent performance of the CES-D in a clinical and community sample of 723 Black men in their 60s (Love & Love, 2006). Two factors measured by the CES-D, depressive affect defined as feeling the blues, sad, lonely, or crying and somatic symptoms such as feeling bothered, poor appetite, and sleep alterations merged into one factor for the group, instead of two. This suggests that physiological and emotional symptomatology resulting from stressors is enmeshed and expression of either is associated with sadness, for the elderly group of Black men. Furthermore, crying responses, a component of the depressive affect factor was instead found to attribute to interpersonal distress, another factor (Love & Love, 2006). Interpersonal distress is characterized by individual perceptions of feeling disliked by others as well as unfriendliness of others (Radloff, 1977). In this sample, crying was perceived most disruptive to social functioning of relationships, and less an expression of sadness associated with depressive affect. This is likely reflective of restrictive emotionality which is the function of societal expectations that men refrain from showing weakness. Overall, the finding from this psychometrics study highlights the uniqueness of experience, perception, and expression of depression in Black males, albeit an elderly sample. Given the performance of the widely used CES-D with a sample of older Black men the sensitivity of this and similar measures warrant further investigation as gender and race insensitivity may significantly contribute to the underestimation of depression incidence in young Black males.

Research and Practical Implications

Research focused on the intricacies of how young Black males interact with the dominant society and depressive outcomes are warranted in response to the staggering social disparities experienced by this population. However, the methods currently used to identify depression in large samples mostly indicate that this debilitating illness is a nonissue. Unfortunately social influences of racism, discrimination, profiling, and harassment continue to affect young Black men today. Furthermore, experiences of undereducation, unemployment, legal institutionalization potentiate impaired self-efficacy and mental illness among these young men. There are psychological, physiological, and sociological manifestations of depression that are unique to this population. Although intersections of race, gender, and class affect experiences as well as expressions of depression in this group, the current DSM provides no specific guidelines or diagnostic criteria for this group. This deficit serves as a springboard for future research.

Practitioners should carefully consider the assessment, history, and screening measures used for identifying depression in young Black men. Specifically, with regard to past legal/justice experiences, employment status, and substance abuse a current and detailed history may provide better insight into the emotional health of these young men. This is especially important as depressive affect and somatic symptoms may be masked by restrictive emotionality, common among Black male subpopulations (Hammond, 2012; Majors & Billson, 1992). Whenever possible, interviews and assessments conducted by Black mental health care professionals, including social workers and nurses, may be especially effective in achieving honest dialogue and in making further recommendations for seeking care. Finally, targeted screening and community mental health outreach for the most vulnerable young Black men residing in inner-city neighborhoods, both residential and homeless, and those who are legally institutionalized is integral to identifying those who are currently affected as well as those at risk. More accurate identification of the true incidence of depression and depressive symptoms within this population will bring more attention to the need for effective intervention(s) and more scrutiny of the larger socioeconomic and political structures that continue to oppress and largely impair this population.