Common mental disorders (CMD), which include depression and anxiety, are a primary global mental health concern. In Britain, women are disproportionally affected by CMD (19 per cent women versus 12 per cent men) and race adds another layer of detriment.
Black women experience higher rates of CMD relative to White British women (29.3 per cent versus 20.9 per cent )1 but are least likely to seek2 and receive treatment3, and are more likely to demonstrate maladaptive coping in response to depression (e.g.,self-harm4).
When black women do seek treatment, they are more likely to be offered pharmacological interventions than talking therapies. And when black women receive talk therapies, they perceive that these services do not understand their experiences, including racism, which can lead to frustration and reduce the effectiveness of therapy5. However, to date, no policy or practice has especially been designed to tackle such inequalities in mental health.
Current policy and practice in the UK (NICE guidelines), do not take account of folk models of depression, nor are they reflective of the marginalised experience of racism. Instead, they are based primarily on research conducted by the thinking of a guideline development group, which was predominantly comprised of white individuals who did not consider gendered racism. Not considering gendered racism in the development of current policy practice could be interpreted as a form of institutionalised racism8, which is distributed as microaggressions throughout the whole health system.
Policymakers may aim to develop policies and practices that are beneficial to all, majority and minority. But, as we are all situated within our own sociocultural identities and experiences, complete objectivity may not be possible9. Critical race theorists have suggested that the dominant racialised group may be subconsciously invested in preserving the system as it continues to benefit them9.
The five-forward review for mental health10 which was accepted by the government briefly mentions aiming to tackle black, Asian and minority ethnic (BAME) mental health inequalities. Especially the over presentation of BAME people in mental health settings, the disparity in the involvement of police during the detention under the mental health act, longer hospital stays after the detention, and the force that features in some of their deaths.
The task force aims to tackle these inequalities by reviewing parts of the Mental Health Act (recommendation 51) and encouraging the Department of Health to ensure the Healthcare Safety Investigation Branch includes deaths from all causes in inpatient mental health (recommendation 56). Yet, in comparison, there is no mention of updating current diagnostic guidelines to address the intersection of race/gender.
Therefore, future developments of policy and practice should consider the intersected identities of service users through stakeholders’ engagement with ethnic minorities with lived experience. To make a sustainable change happen in policy and practice, co-production between service users (particularly those that are marginalised) and service providers is needed. As research on intersectionality12 suggests, it is only through considering multiple demographic factors that we can begin to understand the epidemiology of mental illness and reduce health disparities1314.
Considering the multiple categories of identity, difference, and disadvantage to which people belong (e.g., gender, race, class, age)15 will help us understand the multiple barriers ethnic minorities must overcome to access help for psychological distress. For instance, the oft repeated example of the power dynamics and/or struggles that are associated with discussing experiences of racism that may be impacting their mental health, with a practitioner not of the same race.
We need policies and practices that recognise the difficulties that ethnic minority people face when seeking help for psychological distress. We also need to start training practitioners to be comfortable with discussing experiences of racism. To successfully treat and manage depression in our multi-ethnic/cultural society healthcare, practitioners must be sensitive to the different cultures in order to overcome cultural boundaries26.
Globalisation and continued migration encourage us to continuously negotiate and change the cultural boundaries of management of diseases such as depression. Psychiatrists and other mental health practitioners continually need to become more sensitive to different cultures and be more flexible in their approach to the diagnosis and treatment of patients from ethnic minority backgrounds.
However, this will only be possible if policy and/or practice makers are willing review their current approach and amend it to reflect the marginalised experience of racism. Which means considering the possibility of folk models of depression among ethnic minorities, especially black women, influenced by their intersected identity.
My future research
My MSc thesis will form a pilot qualitative study for my PhD. Black women (above the age of 18), currently not in mental health crisis and stable to engage in conversation around their mental health, will have the opportunity to discuss their experiences of depression with other women that may share their stories. They will have the opportunity to consider and discuss how their intersected race/gender identity may have affected their lived experiences of depression. Please get in touch if you would like to take part: [email protected].
Subsequently, guided by stakeholders, my PhD will be supervised by Dr Janelle Jones and Professor Kamaldeep Bhui in collaboration with Black Thrive and Catalyst 4 Change. Through a systematic review of the literature, focus groups, an international cross-sectional survey, and in-depth interviews, I will explore and test whether beliefs and expectations about what it means to be black and female shape the experience of depression, and whether these intersections, in turn, influence treatment and outcomes.
This project will utilise the Strong Black Women Schema as a theoretical lens, which is a set of beliefs and behaviours that are ‘expected’ of black women16. According to this schema, black women are supposed to exhibit strength through independence, hard-work, emotional suppression, care-giving and self-sacrifice18, which may be related common mental disorders. Findings from my PhD will provide important insights into the lived experiences of black women with depression as well as helping us to identify barriers to treatment and predictors of poor outcomes.
Anna-Theresa Jieman is a budding researcher. She is currently a postgraduate student and Research Assistant at UCL, and a Visiting Lecturer at the University of Hertfordshire. You can read her full bio here.
References
- Appleby, L. et al. Mental Health and Wellbeing in England Adult Psychiatric Morbidity Survey. (2014).
- Adkison-Bradley, C., Maynard, D., Johnson, P. & Carter, S. British African Caribbean women and depression. Br. J. Guid. Couns. (2009). doi:10.1080/03069880802535887
- Maginn, S. et al. The detection of psychological problems by General Practitioners – Influence of ethnicity and other demographic variables. Soc. Psychiatry Psychiatr. Epidemiol. (2004). doi:10.1007/s00127-004-0751-7
- Cooper, J. et al. Ethnic differences in self-harm, rates, characteristics and service provision: Three-city cohort study. Br. J. Psychiatry (2010). doi:10.1192/bjp.bp.109.072637
- Memon, A. et al. Perceived barriers to accessing mental health services among black and minority ethnic (BME) communities: A qualitative study in Southeast England. BMJ Open (2016). doi:10.1136/bmjopen-2016-012337
- Halvorsrud, K., Nazroo, J., Otis, M., Hajdukova, E. B. & Bhui, K. Ethnic inequalities and pathways to care in psychosis in England: a systematic review and meta-analysis. BMC Med. 1–17 (2018). doi:10.1186/s12916-018-1201-9
- Health, N. I. for & Excellence, C. The Nice Guideline on the Treatment and Depression the Treatment and Management of Depression (updated edition). in Depression (2010). doi:10.1007/s00227-002-0869-7
- Essed, P. Everyday Racism: Reports from Women of Two Cultures. (Hunter House Inc., Publishers, 1990).
- Bonilla-Silva, E. Feeling Race: Theorizing the Racial Economy of Emotions. Am. Sociol. Rev. (2019). doi:10.1177/0003122418816958
- Crenshaw, K. Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory, and antiracist politics [1989]. in Feminist Legal Theory: Readings in Law and Gender (2018). doi:10.4324/9780429500480
- Seng, J. S., Lopez, W. D., Sperlich, M., Hamama, L. & Reed Meldrum, C. D. Marginalized identities, discrimination burden, and mental health: Empirical exploration of an interpersonal-level approach to modeling intersectionality. Soc. Sci. Med. (2012). doi:10.1016/j.socscimed.2012.09.023
- Hudson Banks, K. and K.-W. P. Gender , Ethnicity and Depression : Intersectionality in Mental Health Research with African American Women. African Am. Res. Perspect. (2002).
- Cole, E. R. Intersectionality and Research in Psychology. Am. Psychol. (2009). doi:10.1037/a0014564