The Test We Use to Detect Depression Is Designed for White People

Depression looks different for young black Americans and our current screening is leaving many of them undiagnosed.
February 13, 2018, 3:00pm
Electra K. Vasileiadou

When Lauren Carson’s mother wouldn’t let her borrow the family car, something snapped inside the 16-year-old. She grabbed the car keys. When her mom tried to take them back, Carson refused. “I hate you!” she screamed. The two wrestled each other to the ground. Carson broke free and drove the car across the front lawn. Her mom called the police.

It was one of several blowouts between Carson and her mom. When her behavior became more erratic, her parents took her to see a therapist, who diagnosed her with depression. At age 19, not long after starting college at the University of Virginia, she attempted suicide by overdosing on antidepressants. About a year later, she tried again.

Carson’s dad initially thought she was just being a drama queen. And in fact, others might have similarly chalked up her outbursts to nothing more than teen angst. But while they might not have fit the “conventional” pattern of depression symptoms, such as social isolation and excessive crying, research suggests they do fit the pattern seen in black youth like herself.

A recent study found that a widely used depression screening test, known as the Center for Epidemiologic Studies Depression Scale (CES-D), though effective in detecting depression in white adults, may not do as good a job in black youth who live in public housing. Researchers saw that these youth tended to express their depression differently from other demographic groups—typically through complaints about conflicts with others, as well as physical pain or discomfort.

While Carson describes her family’s socioeconomic status as “middle class,” and did not live in public housing, there is “absolutely overlap,” culturally, says Alfiee Breland-Noble, associate professor of psychiatry at Georgetown Medical School and director of the AAKOMA Project, an initiative to address the mental health needs of youth of color. Black youth across socioeconomic backgrounds would experience, for instance, racism and similar signs and symptoms of depression.

Still, it’s not clear whether we would see the same pattern in, say, more affluent black youth living in the suburbs, Breland-Noble says. “I also caution us to be careful and not assume that the experiences of youth in poverty are universal and representative of all black youth given that most do not live in poverty,” she adds. Both low-income and more affluent youth can have depression, but the factors contributing to it would differ—community violence, for example, versus being one of a few black students at their school.

Indeed, studies suggest socioeconomic status can also strongly influence how people express their depression, so much so that accounting for it seems to narrow the racial differences in symptoms seen in earlier research. When researchers controlled for socioeconomic status in a 2011 study of major depressive disorder, black participants reported experiencing most symptoms, including depressed mood, and changes in weight and appetite, as frequently as their white counterparts. Another study found that low-income black and white mothers in the rural South described their depressive symptoms in much the same way. For instance, both groups of mothers said they had experienced uncontrollable crying, a desire to be alone, and changes in weight and appetite.

Other depression screening tests may have similar limitations as those of the CES-D. “Many were developed by studying middle class white women, so the language that was chosen [to describe depression] represents that cultural experience,” says Sean Joe, professor at the Brown School of Social Development at Washington University in St. Louis. The bias toward using white women’s experience of depression to define symptoms for diagnosis may underlie a phenomenon researchers call the “black-white paradox”: Although blacks in the US experience higher rates of racism and other social inequalities that should make them more susceptible to depression than whites, national surveys have found that they have lower rates of major depressive disorder. But it may just be that current screening tests under-diagnose depression in black Americans, Joe says.

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Left undiagnosed—and therefore untreated—depression can lead to not only violence and other mental health issues, but also suicide, whose rates have risen among black youth. Although the rate of suicide among white children fell between 1993 and 2012, the rate among black children nearly doubled. And in blacks ranging from 15 to 24 years old, suicide ranks as the third-leading cause of death.

The CES-D asks individuals how often they identify with a series of 20 statements, such as, “I felt fearful” and “I had crying spells.” Studies have found that the way people typically express their depression falls into four categories: feelings of sadness; lack of feelings of happiness; interpersonal problems, like feeling as if others are acting unfriendly to them; and physical symptoms, like poor appetite. But this four-category model was based on analyses of primarily white adults’ responses to the CES-D.

The aforementioned study that examined depression in low-income black youth found that compared to members of other demographic groups in which the CES-D had been tested, black youth in the study were more likely to respond that they experienced physical symptoms and interpersonal problems, and less likely to explicitly express their depressed feelings by responding, for instance, that they felt sad or had crying spells.

One of the lead authors, Wenhua Lu, an assistant professor of childhood studies at Rutgers University, observed that their symptoms followed a two-category model suggesting they may “have trouble differentiating” feelings of sadness from physical symptoms and interpersonal conflicts. But Breland-Noble prefers to describe it as reflecting the holistic understanding of health in black and other communities of color, which doesn't draw a distinction between mind and body. "The way [black Americans] make sense of depression is by saying not just how they feel, but what’s happening in their body and how does it impact them when they interact with the people they love," she says.

The study’s findings might also reflect the deep stigma against mental illness in the black community, where "it's more acceptable to complain if it's physical or about something interpersonal," Breland-Noble says. "It's almost a cry for help.” She adds that the youth in the study probably already struggle with the stigma of being poor and black; explicitly expressing their feelings of depression would only add the stigma of having a mental illness on top of that.

Growing up, Carson navigated the stigma about her depression in similar ways. Her dad saw her diagnosis as “shameful,” while her friends said she shouldn’t take antidepressants because “black people don’t take medication.” It was much easier to complain about the headaches that seemed to flare up during her depressive episodes. Shortly before her first suicide attempt, she fought on and off with her mom, hoping her outbursts would concern her enough to intervene. Now 29, she serves as the executive director of and founder of Black Girls Smile, a nonprofit that seeks to empower young black women to manage their mental health.

Lu says her findings suggest that “clinicians need to consider potential cultural and racial differences in the expression of depression among racially and ethnically diverse adolescents, especially black adolescents.” By looking only for the “conventional” pattern of symptoms—those seen in white adults—they may fail to spot depression in black youth and other young people of color. Breland-Noble adds that understanding how depression looks in these youth makes it harder to misattribute acting out to conduct disorder—a range of disruptive behaviors that includes starting fights and bullying. In fact, black and Latino boys may use anger as a cover for depression. After all, “what’s more acceptable: for you to be in a corner crying, or to be in someone’s face?” she asks.

Linking anger to depression may also make it harder to criminalize black youth for it. Compared to white children, black children are nearly four times as likely to be suspended from school, and nearly twice as likely to be expelled, according to a report by the NAACP’s Legal Defense and Educational Fund. And the increased presence of law enforcement in schools has made it more likely that a kid showing “problem behavior” will land in the juvenile justice system, and in turn, prison.

The unique ways black youth express depression could also help guide treatment, Lu says. For instance, these youth might especially benefit from interpersonal psychotherapy, which focuses on interpersonal relationships, including dealing with any conflicts that emerge.

Breland-Noble notes that the study represents a “critical first step” in highlighting the importance of research on depression in different demographic groups. “It opens people’s eyes and interpretation of what depression can look like. ‘Sad’ isn’t necessarily the only way.”

Carson agrees. “Hopefully it will show that there’s more going on in black youth’s lives than we know of,” she says. “A lot of black youth have been dehumanized. They grow up so quickly in the eyes of society…I’m hoping this study will humanize these youth again.”

Update 2/13/18: This article was updated to include two additional studies' findings.

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