Populations
Ethnicity, Poverty, and Oppression
For many of us, depression gets an ample assist from our lot in life.
John, an African American aged 10, entered an elevator with his father. Two men inside started arguing, one drew a gun and fired. One of the bullets hit John’s father in the stomach, who died almost instantly on the moving elevator. The boy’s first reaction was to vomit, a nausea his mind would not let him forget.
Welcome to the dark side of the rainbow coalition, where a perfectly normal boy can be turned into a mental health case in just a few short seconds. John’s story is from the Surgeon General’s recently released Mental Health: Culture, Race, and Ethnicity, which is a supplement to his 1999 landmark "Report on Mental Health." According to the Supplement: "More than 40 percent of inner city young people have seen someone shot or stabbed. Exposure to community violence, as victim or witness, leaves immediate and long-term effects on mental health, especially for youth." Not surprisingly, between 1980 and 1995 the suicide rate amongst African American youths aged 10 to 14 increased 233 percent.
An Ethnic View of Depression and Bipolar Disorder
The Supplement examines mental health issues facing four broad ethnic groups, including African Americans, American Indians and Alaskan Natives, Asians and Pacific Islanders, and Hispanic Americans. Even though there is very wide diversity across and within these groups, the Supplement notes they all face a social and economic environment of inequality that takes its toll on mental health. In addition, if these people happen to be poor, they share a decided lack of access to treatment. Other common factors include mistrust of the system, stigma, communication difficulties, and stereotyping. To cite a small sampling of facts from the Supplement:
- 43 percent of African Americans and 28 percent of Latinos felt their healthcare provider treated them badly because of race or economic background as opposed to five percent of whites.
- In some Asian cultures, mental illness is thought to reflect badly on family lineage, and diminishes marriage and economic prospects for other members.
African Americans are overdiagnosed for schizophrenia and underdiagnosed for bipolar disorder. - African Americans and Asians in general are slow metabolizers of certain antipsychotics and antidepressants. Physicians unaware of this may prescribe doses that are too high, resulting in severe side effects and noncompliance.
- One third of American Indians and Native Alaskans do not have a doctor or clinic that can provide regular or preventive health care.
- Many Southeast Asian refugees are at grave risk as a result of the traumas they experienced before and during immigration to the US - for Vietnamese the fall of Saigon, for Cambodians the killing fields, for Laotians losing one-third of their population in war.
- Mexican immigrants who lived fewer than 13 years in the US had surprisingly lower prevalence rates for depression and other disorders than Mexican Americans born in the US.
The final facts are real eye-openers: In 1990, 23 percent of US adults and 33 percent of US children were from racial and ethnic minorities. In 25 years those figures are expected to leap to 40 and 48 percent respectively. Likewise, these populations have been fanning out across the US. For instance, the Latino population doubled over the past decade in Georgia, Tennessee, and other states. We may still live in an us-them society, but sheer numbers and proximity now make "their" concerns "our" concerns. We now know bipolar is an equal opportunity illness while depression strikes hardest amongst the poor and traumatized. Our days of innocence are over. Our time for outreach has come.
More on Ethnicity and Depression and Bipolar Disorder
The Depression and Bipolar Support Alliance featured a very timely session on ethnic disparities at its conference held in Cleveland in August 2001. Renato Alarcon MD, MPH of Emory University noted that the US has the fifth largest Spanish speaking population in the world, with the largest Puerto Rican population in the hemisphere, and the second largest concentration of Cubans, Salvadorans, Haitians, and Jamaicans. Mexicans account for 64 percent of all Hispanic Americans. Hispanics are the youngest demographic group, with a median age of 26 compared to 38 for whites.
The Spanish population in the US now numbers 36 million, a 700 percent increase in 40 years, but of these 36 million, one third are uninsured, half do not have personal physicians, and about 30 percent of the immigrant population are depressed. Culturally determining factors for underuse of mental health services include: overprotectiveness of family members against strange and feared social institutions, masking mental disorders by drinking and other behaviors, pride or embarrassment or shame, preference for folk healers, and language barriers.
William Lawson MD, PhD of Howard University noted that 40 percent of African American children are raised in poverty. African Americans earn only 60 percent of the median income, and possess just ten percent of family wealth. They are more likely than whites to pay out of pocket, and their treatment is more likely to be terminated quickly. Nevertheless, they end up in the hospital more and are more likely to be treated with old generation antipsychotics. Clinicians tend to misinterpret cultural idioms as psychotic features while underdiagnosing for bipolar and depression. Not surprisingly, African Americans distrust the mental health system, but that fear also harkens back to the bad old days when blacks were unethically experimented on (the Tuskegee experiments the most notorious example).
Prof Lawson strongly emphasized the need for more outreach. Washington DC, for example, with a predominately African American population has no DBSA chapters.
Kinike Bermudez, Consumer Program Director for the MHA of Greater Dallas and a spokesperson for Asians and Pacific Islanders, noted that 40 percent of Southeast Asian refugees suffer from depression, 35 percent from anxiety, and 14 percent from PTSD. The portrayal of Asians as the model is a myth, she said. The suicide rate among elderly Chinese American women is ten times that of white elderly women.
Native Hawaiian youths have higher suicide rates than the general population. Mainlanders get most of the good jobs, outsiders are living on their land, with hotels on their sacred grounds. These are things you’re not going to learn when you’re in Hawaii, she observed.
There is a platinum rule, she concluded, that is not about golden rules. It is treating others as THEY want to be treated.
Down and Out
When depression hits someone in the middle class," writes author Andrew Solomon, "it’s relatively easy to recognize. "You’re going about your essentially okay life and suddenly you begin feeling bad all the time." And, inevitably, as you plunge toward the point of no return, you are going to attract the attention of your friends, coworkers, and family.
Way over on the other side of the tracks, by contrast, the ebb of serotonin is decidedly more subtle, hardly making ripples as it drains victims of their vital forces and lends new meaning to the term, life sucks.
Andrew Solomon's 2002 "The Noonday Demon: An Atlas of Depression" covers a wealth of material, but it is when he is writing about poverty that he is at his most passionate and authoritative. According to figures cited in the book, 42 percent of heads of households receiving Aid to Families with Dependent Children meet the criteria for clinical depression - more than twice the national average - and 53 percent of pregnant welfare mothers are in the same condition.
"Virtually all of America’s indigent," he writes, "are, for obvious reasons displeased with their situation; but many of them are, additionally, paralyzed by it, physiologically unable to conceive of or undertake measures to improve their lot. In this era of welfare reform, we are asking that the poor pull themselves up by their bootstraps, but the indigent who suffer from depression have no bootstraps and cannot pull themselves up."
Take Ruth Ann, born in a trailer in rural Virginia, a school dropout, pregnant at 17, one failed marriage, the second failing, with two kids she was having trouble supporting, a prostrate picture of fat and misery. By good fortune, her doctor got her into a University of Virginia study where she received excellent treatment. Soon after, she began working as a part time temp, then became office manager, and later she and a friend bought out the business. Somewhere along the way, she ditched her husband, began working out and dieting, and is now down to 135 pounds from 210. Equally as important, she has forged a new relationship with her kids.
Sound too good to be true? Andrew Solomon’s editors for the magazine version of his poverty chapter were skeptical, as well. First, he says, the lives of the people he wrote about were implausibly horrendous, and second their recoveries were too quick and dramatic to be believed. "The truth I had discovered," he wrote, "was intolerably stranger than fiction."
But Andrew knows when he is on to something, and won’t let go. Now he asks us to stand an assumption on its head: Instead of only attacking poverty by improving a poor person’s exterior world, why not also change things inside, where depression lurks? No, handing out Prozac will not dupe the poor into thinking they are happy. But with the removal of one crushing burden, the dispossessed would at least have something of a fighting chance. As the author explains in language a fiscal conservative would understand:
"If one makes the conservative estimate that 25 percent of people on welfare are depressed, that half of them could be treated successfully, and that of that percentage two-thirds could return to productive work ... that would still reduce welfare costs by roughly $3.5 billion a year."
But don’t hold your breath waiting for anything to happen. This is not exactly an era of trickle up economics we are living in. One day, perhaps, people in power may listen, but first we need Andrew Solomon and many more like him demanding to be heard. Sequel, Andrew, sequel.
Reality Check
In another chapter, Andrew Solomon explains the political realities, based on an interview with Senator Pete Domenici (R - New Mexico):
"'If you’re asking whether we can expect much change simply because the change would serve everyone’s advantage in both economic and human terms,’ said Domenici, ‘I regret to tell you the answer is no ... We are now niched with programs and program costs ... The question we must confront is whether the program you’re describing is going to grow and require new funds, not whether there’ll be some overall saving for the Treasury of the United States.’ You can’t immediately reduce other costs: you can’t in one year take the money out of the prison system and out of welfare to pay for a new mental health outreach service, because the economic advantages of that service are slow to accrue. ‘Our evaluation of medical delivery systems is simply not outcome-oriented,’ Domenici confirmed."
In addition, Republicans don’t like to mandate states and other providers, it is difficult to get people who are elected for limited terms to focus on long-range improvements, and, in the words of the late Senator Paul Welllstone (D - Minnesota), "indigent depressed people are home in bed on election day with the covers over their heads."
The Mark of Oppression
It's a damn confusing time to be black," writes Erin Aubry-Kaplan in an article at Salon.com. "Never before in history have blacks loomed so large in the public imagination and public culture yet been granted so little space as real people."
The article takes an extended look at a new book, Lay My Burden Down: Unraveling Suicide and the Mental Health Crisis Among African Americans by Alvin Poussaint and Amy Alexander. While Alvin was going to Columbia University and staking out his future as a psychiatrist, his brother Kenneth
was shooting heroin en route to an early death. Alvin calls his brother's destructive behavior a "slow motion suicide."
Ironically, black people are experiencing higher rates of depression and suicide at a time when they are entering the middle class in ever-increasing numbers. The suicide rate among young black men has doubled since 1980. Young blacks also account for 50 percent of all homicide deaths in the US in what only can be described as a form of suicide, according to Dr Poussaint.
"Undoubtedly, great strength allowed black people to survive slavery and discrimination," the authors write, "but the notion that black men and women can easily handle burdens that would psychologically crush other people has been oversold."
In Georgia, a report noted that the number of black males ages 15-24 who committed suicide in 1994-98 was 40 percent higher than during the same span 10 years earlier. According to Dr Allan Josephson, chief of child, adolescent and family psychiatry at MCG, quoted in the Atlanta Journal-Constitution: "Black males don't go to psychiatrists."
Meanwhile, from across the ocean, a seemingly unexceptional abstract of a study turned up in the NIH database - unexceptional, that is, but for two features. The study found that 53 percent of a sampling of students who visited the health service at the University of Transkei in South Africa
suffered from mild to severe depression.
A quick search revealed that Transkei was a "homeland" carved out of South Africa in the 1950s as part of the government's infamous system of apartheid. In the 1970s, South Africa established Transkei as a separate "country," legally depriving its Xhosa-speaking people of what little rights they had as South African citizens. Later, when apartheid was abolished, Transkei was reincorporated into South Africa, along with citizenship for its residents.
The study abstract makes no attempt to connect the dots, but it is fair to assume that apartheid has left gaping wounds that are a long way from being healed.
In the meantime, we know what stress and trauma can do to the wiring in our brains. In the words of Charles B Nemeroff, MD, PhD and Noha Sadek, MD, writing in Medscape: "In addition to genetic factors, early loss of parents, inadequate rearing by parents, and lifetime trauma [are] considered
to be risk factors for subsequent development of affective disorders."
Oppression, it turns out, is as subtle as it is brutal, leaving its mark on new generations who must learn to cope in changing environments of new hopes and expectations. Even when things get better, we know we are dealing with a major social concern. Equally as significant, we need to recognize the lingering mark of oppression as an important public health issue.
Published in 2001, reviewed Feb 15, 2008
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