Culture, Depression, and Coping Mechanisms among African Americans

Culture is a dynamic force that significantly affects health. It comprises beliefs, norms and values, and determines how populations view certain things. In the area of mental health, it determines whether one will seek help or not, the type of help they will seek, the type of support system they will have, and how they will cope with mental illness. There are six racial groups in the United States, each with its unique sub-culture. Belonging to the African American racial group, African Americans have their perceptions about mental illness, stigma, treatment and care, as well as preferred coping mechanisms. This paper discusses the effects culture has on depression among African Americans. It also examines the coping mechanisms this population employs to deal with depression, and proposes strategies for addressing their mental health issues.


Introduction
Mental illness are conditions or disorders that affect a person's thinking, feeling, mood, or behavior.
They often affect a person's ability to relate to others and for some individuals, result in severe impairments that interfere with their ability to carry out daily activities. Mental illnesses may be occasional or long lasting (chronic) and include conditions such as depression, anxiety, bipolar disorder, and schizophrenia, all of which vary in degree of severity. Mental illnesses have been classified into two main groups; any mental illness (AMI) and serious mental illness (SMI) (Ward & Heidrich, 2009). In 2017, an estimated 46.6 million adults aged 18 or older in the US had AMIs, accounting for 19 percent of all US adults (National Institute of Mental Health, 2019). In that same year, the prevalence of AMI, was about 22 percent in women and 15 percent in men. Also in 2017, about 11.2 million adults over the age of www.scholink.org/ojs/index.php/rhs Research in Health Science Vol. 5, No. 3, 2020 103 Published by SCHOLINK INC. 18 in the US had SMIs, accounting for about 5 percent of all adults in the US, with women (6 percent) having a higher prevalence than men (3 percent) (National Institute of Mental Health, 2019).
Depression is one of the most prevalent mental health disorders in the US that often goes underdiagnosed and untreated. It presents with depressed moods and affects all genders, races, ethnicities, and people of all walks of life (Bailey, Mokonogho, & Kumar, 2019). Depression is associated with culture and poor socioeconomic status (SES) and has been identified as one of the most common psychiatric disorders in the US, affecting over 12 million women (12 percent) and more than 6 million men (7 percent) in a given year (National Institute of Mental Health, 2020). In a recent national survey, a depression lifetime prevalence rate of 10.4 percent was reported among African Americans (Williams et al., 2007).
Survey results also showed that African American women (13.1 percent) had a higher prevalence of depression compared to African American men (7.0 percent), which is consistent with available literature (National Institute of Mental Health, 2020). Findings from a 2020 survey launched by the US government intended to assess the effects of COVID-19 on Americans, found that depression rates among African Americans rose to 41 percent (about 1.4 million people) a week after the video on George Floyd aired (Fowers & Wan, 2020). Without appropriate mental health treatment, depression can cause significant distress, disability, impairment, poor quality of life, increased mortality, and poor health outcomes. In the US, the burden of disability associated with depression is greatest among African Americans.
Although African Americans suffer less than Whites from acute episodes of depression, they are more likely to suffer from prolonged, chronic, and severe debilitating depression with serious consequences. In examining risk factors for depression among African Americans, Shim et al. (2012) identified culture and perceived racial discrimination in particular, to be strongly associated with worsening mental and physical health among this population (Shim et al., 2012). In addition to culture, race, ethnicity and stigma, were further key risk factors identified (Shim et al., 2012). This paper discusses the effect culture has on depression among African Americans. It also examines the coping mechanisms this population employs to deal with depression, and proposes strategies for addressing their mental health issues.

Culture and Depression
Culture is behavior and experiences that are learned and shared. It is also a way of life and the unique set of characteristics that set a group of people apart from other social groups. Culture is influenced by conscious beliefs and affects the way people think about, look at, express, and define their world (Noguchi, 2014

Cultural Perceptions
Cultural perceptions prevent African Americans from accessing mental health services to deal with their depression. Within African American culture, treatment seeking behavior for mental health disorders is perceived as a sign of weakness and considered an issue to be resolved within the family unit, or by the church. In a study conducted on African American perceptions on depression, most participants stated that they did not believe in mental health treatment in particular or medical treatment in general. Participants felt that mental health professionals could not be trusted, particularly those who were White. Their negative feelings towards White mental health professionals largely stemmed from how health systems have treated African Americans in the past (Conner et al., 2010). Other participants of the same study believed that the cause of their depression was simply due to their old age and that, it was a "normal" part of the aging process and therefore, did not warrant the utilization of services. To them, there are certain things that one can change, and other things that cannot be changed. Many participants believed that if one had true inner strength, they would not let depression get a hold of them, and as a result, they would not need to seek professional help (Conner et al., 2010). African American beliefs about mental health and depression also cause them to shy away from seeking treatment. Often, these beliefs are based on myths and cultural folklore that contain very little factual information. One myth identified in a study is the belief that mental health treatment is not effective at relieving depressive symptoms and that, there is no cure for depression (Conner et al., 2010).

Provider Bias and Miscommunication
Culture plays a crucial role in mental health because it bears upon what people bring to the clinical setting.
It accounts for how people communicate their symptoms, which ones they will report (Office of the US Surgeon General, 2001), and the meaning they ascribe to their mental health status. Culture also shapes mental health provider conduct and interaction with patients during diagnosis, treatment, and care (Office of the US Surgeon General, 2001).
A key indicator of satisfactory mental health care is how a patient feels about the way they have been treated by a provider. Unfortunately, many African Americans who have utilized mental health services in the US, say that they are dissatisfied with the service they receive (Cuevas, 2013). This is because of the biased attitudes that some White mental health care providers display towards their race, cultural beliefs, and practices (Cuevas, 2013). Often times, White mental health care providers make unwarranted judgments about African Americans (Snowden, 2003), and are less likely to provide those who seek care, with guideline-adherent treatment for their depression (Young et al., 2001 discrimination at the hands of their mental health care providers expect very little from them and thus, do not take their recommendations seriously (Cuevas, 2013). This explains why by the time some African Americans go back to seek mental health care, they are at an acute stage of mental illness. Generally, African Americans prefer mental health care providers who are of the same race as them, so they can receive care that is culturally appropriate.

Stigma
The stigma associated with depression in the US varies by race. It is determined by the cultural perceptions associated with the condition and elicits different emotional reactions. Within African American culture, the stigma associated with depression brings about feelings of fear of social judgement, rejection, and discrimination (Wong et al., 2017). It causes people who belong to this racial group to feel that they will not be taken seriously by anyone in society if it is known that they have been diagnosed with depression. It further causes them to feel that they will be considered dangerous and less competent to handle their own affairs. As a result, many African Americans are hesitant to openly discuss their depression. They choose not to seek medical attention even though they may need it (Campbell & Mowbray, 2016).

Depression Coping Mechanisms
According to Lazarus and Folkman (1984), coping is the constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as stressful or exceeding an individual's resources. These efforts, they say, range from seeking professional help to ignoring the problem. The mental health treatment-seeking literature suggests that African Americans prefer to cope with their depression than to seek professional help, hence their utilization of various informal strategies such as religion, self-reliance, "frontin", and denial (Conner et al., 2010).

Religion
The influence of religion on African Americans cannot be ignored. Recent studies from Pew Research indicate that, African Americans are more religious than the rest of the US population, with an estimated 87 percent of this population engaging in religious activities and church attendance (Pew

Research, 2009).
For African Americans, the first instinct when depression sets in is not to seek professional or medical help (Bailey, Mokonogho, & Kumar, 2019). Their first instinct is to turn to religion to find a sense of purpose and to obtain guidance for healing (Richman & Caple, 2018). This coping mechanism involves praying to God to take away the depression, reading inspirational scriptures for comfort or relief, talking to a minister or chaplain to help work through the depression, or using other religious thoughts or behaviors to relieve the condition. High religiosity and spirituality have been reported to positively reduce depressive symptoms among adult African Americans (Hovey et al., 2014).

Self-reliance
In a study conducted by Conner et al. (2010), self-reliance was a common strategy identified by African American adults for coping with depression. According to participants, when they felt depressed, they did things to feel better such as staying active in the community, cooking, and cleaning. Seeking professional mental health treatment was often not an option. It was a last resort, after they had tried other strategies to manage their depression on their own (Conner et al., 2010). Participants also indicated that they believed they had the power to handle their depression on their own, and that if they were strong enough, they could beat the condition. To the participants, not handling their depression by themselves meant that they were weak and lacked personal strength (Conner et al., 2010).

"Frontin" and Denial
To cope with depression, some African Americans engage in "frontin" -hide their mental health status from other people (Conner et al., 2010). The notion is that, if people do not know about their condition, then they will not have to deal with the issue or seek help. In addition to "frontin", some African Americans cope with depression by telling themselves that what they are experiencing is not depression regardless of the facts. This is the case especially where they are caretakers of other people, or have children or grandchildren (Conner et al., 2010).

Proposed Strategies
To address the effects of culture on depression among African Americans, a number of things have to be done, including providing education on depression to dispel myths and the need to seek help, integrating religion into mental health care, and providing social support.

Education
Information on depression should be disseminated through outreach education in trusted community settings frequented by African Americans such as barber shops, salons, and churches. This strategy was used to improve upon the health outcomes of African Americans suffering from hypertension and cancer (Hess et al., 2007) and could help to address the issue of depression. Given the way African Americans feel about depression and seeking out care, online consultation for depression should be an option provided to this population. This platform is anonymous and may be a more appealing way for African Americans to learn about depression and to subsequently seek care (Houston et al., 2001).
Depression education needs to be designed in a way that specifically targets African Americans, so they see that it relates to them. The content of the education effort should focus on dispelling negative cultural beliefs and practices that cause or contribute to depression. The media (mass and social) can help by presenting people with depression in a positive light, so African Americans with depression can seek care without the fear of stigma or social judgement.

Integrating Religion into Care
Mental health care provider understanding, and appreciation of the role religion plays in the life of their patients will show that they are empathetic to their needs. This will build trust and cause their patients to be comfortable to access care for their mental health needs (Richman & Caple, 2018). Integrating religion into mental health care is still a controversial issue, although a growing body of evidence www.scholink.org/ojs/index.php/rhs Research in Health Science Vol. 5, No. 3, 2020 107 Published by SCHOLINK INC.
shows its beneficial effects (Hefti, 2011). Seeing religion is important to African Americans, it is important for mental health care providers in the US to include this dimension in the treatment of this population. They can do this by working with their African American patients to integrate spiritual goals into their treatment plans (Hefti, 2011). Such goals may include strengthening their relationship with God so as to be able to cope with their depression, persevering in difficult depressive circumstances, and being more aware of God's presence and guidance in their daily life. These spiritual goals should align with and not conflict with other biomedical treatment goals (Hefti, 2011).

Improve Provider Cultural Competence
Cultural competence is a set of behaviors and attitudes that allow mental health care providers to communicate effectively with patients of various cultural backgrounds and to provide care that is appropriate to their cultural needs. If mental health care providers are culturally competent, it will remove some of the barriers (e.g., such as stigma, and the fear of being under or misdiagnosed) that prevent African Americans from seeking care for depression. When mental health care interventions are tailored to cultural needs, they become four times more effective in improving health outcomes, because they increase patient knowledge, decrease access barriers, and develop culturally competent providers (Hu et al., 2020).

Ward and Brown developed a culturally adapted depression intervention called Oh Happy Day Class
(OHDC) for African Americans with depression (Ward & Brown, 2015). The primary goals of the intervention were to increase retention in treatment, increase satisfaction with treatment, and decrease symptoms of depression (Ward & Brown, 2015). Results for Pilot one showed that, 73 percent of African Americans completed the full OHDC intervention. It also showed a significant decline in depression symptoms from pre-to post intervention. The OHDC was modeled after the Coping with Depression Course, an intervention in which in-group counseling individuals learn how to cope with depression.
Implementation of the OHDC intervention revealed that African Americans had some knowledge about mental illness and wanted to increase their awareness on the condition (Ward & Brown, 2015).

Social Support Networks
Given the fact that culture affects the mental health of African Americans and causes depression, it is important that this population has good social support networks that they can turn to, should they become at risk for the condition. Social support networks provide psychological, material resources, and assistance to people in times of need (Cherry & Morin, 2020) and usually comprises a network of family members and friends. Mental health care providers and researchers emphasize the importance of having strong social support networks to deal with depression and other mental health issues.

Conclusion
Examining the effects of culture on depression among African Americans and the coping mechanisms they employ, provides insight into the prevalence of depression among this population, and helps to explain why they are unwilling to seek and utilize mental health services. It also provides opportunities for addressing depression among this population.