Racism is an uncomfortable truth—and the discomfort is on the part of the people experiencing it. Those feelings should come before our discomfort with looking the truth in the eye.
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Editor’s note: “What is an article about racism doing on a health-focused website?” some of you may be wondering. In our current social climate, talking about race can be extremely triggering and uncomfortable. But, we made a commitment to talking about awkward health conversations – no matter how uncomfortable they make us feel. This isn’t just an opinion piece: this is a well-researched article on how racial bias can have damaging effects on someone’s mental health. It’s a long read, but a great one. Now, sit back and get uncomfortable.
Racism is a topic that dominates headlines. Whether it’s a footballer taking a knee to protest unwarranted police violence against black citizens; or the knee-jerk reactions of world governments over the immigration of brown bodies as they rush to stymie “unwanted” demographic shifts by building walls and seam-ripping treaties. But far from these front lines, racism is the daily reality for people of color (POC) and minority groups. It is a more softly-spoken monster that roars into areas we often don’t consider.
Mental health is one of those areas. Racism ought to be a frame we put around medical discourse in general, but while racism has a seat at the table in socio-economic and political discussions, it is nearly forgotten when it comes to health care—especially concerning mental health. This silence hides what a massive role discrimination plays in the formation of staggering mental health statistics among minorities.
Black persons are 10 percent more likely to experience major depressive disorder (MDD) than white counterparts, and those are just the cases that go reported. Despite being the most affected group, black Americans are the least likely to seek treatment for their symptoms, and the most likely to cease treatment before their recommended course of therapy. They are also the most misdiagnosed and over-medicated group. Why?
Too often, racism has allowed the medical community to point the blame inward: “If a certain group has more trouble than another, it must be their own fault.”
It is almost impossible to have a well-rounded discussion on the barriers placed on racial minorities without understanding how discrimination-based depression preys on these communities. Depression is responsible for decreased economic opportunity, increased social isolation, and negative physical manifestations like high blood pressure and elevated heart rate. Living in a more aggressive, less secure society is a key factor in the creation of depressive symptoms, and ignorance of this is a significant factor in misdiagnosis.
In this article, we’re going to explore the science of racism: how stress caused by racial discrimination changes cortisol levels, why modern medicine isn’t culturally competent, and where the stigma for POC seeking healthcare comes from.
It’s time to turn the question outward: “How is racism responsible for high rates of depression?”
Depression statistics: everyday effects
Before we dig into the explicit link between racism and depression, it is important to have background on the disease itself. When we say ‘depression,’ what does that mean? Who is suffering from it? How does it manifest, and what are its effects on everyday life?
Demographics surrounding depression can be tricky—much of it goes misdiagnosed or underreported. Still, according to the World Health Organization, 300 million people worldwide are currently suffering from depression. In the last year in the U.S. alone, 16.2 percent of the population experienced a ‘major depressive episode,’ and it is estimated that 15 percent of the total adult population will experience depression in their lifetime. Moreover, these numbers take a predictable turn—they are higher in women than men, and higher in those who identify as bi-racial or a minority identity. Here is our first clue that less social equality might be a predictor of who is at-risk for depression.
Part of the stigma surrounding depression stems from the notion that depression is for teenagers, that adults ‘get over it’ by growing out of it. But despite what a plethora of broody movies starring 20-something-year-old actors in copious eyeliner playing teens struggling through perennial mood swings might tell us, the median age of onset for depression is 32.5, and adults between the ages of 18-25 are the most likely to be affected.
Depression is one of the predominant mental health issues in the world and a leading cause of life under disability. Yet, according to the Anxiety and Depression Association of America, less than 40 percent of those suffering from depression receive treatment.
Environmental factors have long been labeled as a trigger for sustained or onset depression. Stress from work and school play a role, and the more insurmountable or hopeless a personal situation may seem (bills, debt, childcare, divorce), the more likely someone is to stumble on the mental gymnastics of ‘just getting by.’ And depression often functions as a vicious cycle— kids with anxiety and depression are at a higher risk of performing poorly in school; they socialize less, and are more likely to engage in substance abuse. Adults suffering from depression are less likely to go for work promotions, take bodily care of themselves, or invest in future-planning.
Already, many of these effects begin to look like statistics we already recognize from discourse surrounding racism and education or racism and economics.
It is important to note that depression manifests differently in separate population sub-groups. In adult men, it is most likely to appear as exhaustion, short-temper, increased reckless behavior, and substance abuse. In black men especially, it manifests as a failure to recognize symptoms and seek treatment due to a fear of perceived weaknesses. This can affect family life, economic opportunity, and society’s interpretation of race—if 10 percent more black Americans have depression than white Americans, and substance abuse is a manifestation of depression, then the easy, lazy (and incorrect) conclusion to come to is: POC have naturally higher rates of substance abuse. This brand of torpid analysis furthers a false narrative that leads black communities to seek help less often. If substance abuse is framed as a ‘symptom of blackness’ rather than a ‘symptom of depression,’ sufferers are less likely to realize that they need help.
In women, depression usually manifests as a sense of melancholy, unworthiness, and guilt, leading to higher rates of accepting unacceptable behavior, like physical or emotional abuse or less risk-taking. Depressed women are less likely to aim for promotions, higher pay or higher education.
In young children, depression manifests as anxiety and refusal to go to school. They become nervous when left alone by parents, and this codependence means they do worse in schools and daycare while preoccupied by their anxieties.
In teens, it manifests as petulance, moodiness, poor scholastic performance, and can often turn into eating disorders or substance abuse issues. This can cause previously good grades to plummet, causing a significant shift in confidence, and cementing feelings of unworthiness. Depression also encourages poor body image—the idea that one is ‘naturally ugly.’ In cultures where a minority look is not the definition of mainstream beauty, this can be especially easy to slip into.
In older adults and the elderly, depression often manifests as grief—often, a major cause for depression in later life is the onset of physical illness and the lonesomeness that comes with that burden. Persons already being quiet about physical ailments will be less likely to seek help for mental ailments.
Over the last decade, incidences of depression have risen dramatically—especially in younger subsets—within black communities. In the study, Depression among black Youth; Interaction of Class and Place (Assari, Gibbons, Simons, 2018), it was further deduced that black youth living in predominantly white neighborhoods experienced much higher rates of depression, and so did black youth living in higher-income households. Generally, wealth for POC was an indicator of living in a predominantly white neighborhood as well as POC youth attending mostly white schools, due to pervasive economic inequality between whites and blacks and a history of neighborhood planning based on ‘white flight’ and gentrification. While high income is a guard against the risk of MDD in white populations, the same is not true for black adult populations. A key driver for this is ‘white hostility,’ rather than ethnocentrism.
According to The British Journal of Psychiatry’s article titled, Does Racial Discrimination Cause Mental Illness (Chakraborty, McKenzie, 200), ethnic minorities are likely to suffer from mental illness in line with how small a percentage of the local population they are, especially in the U.S. and the U.K. A 2001 study in London noted this on a micro-scale—in predominantly white London neighborhoods, ethnic minorities were two times more likely to have mental health issues than their colleagues in racially diverse neighborhoods. That is not to say that the neighborhood had to be predominantly black, Arab, or otherwise for incidences of negative mental health to decrease in those populations. Just that the community had to be diverse for this effect to be lessened, regardless of the majority population, even in communities where the majority was white—but not overwhelmingly white. The effects on suicide in POC, measured separately in other studies, showed similar trajectories.
MDD is the most common form of depression and a leading cause of disability in the U.S. and the U.K., especially among people aged 15-44. General symptoms include melancholy, loss of pleasure and interest in life, loss of appetite, insomnia, suicidal thoughts, cognitive difficulties, as well as social, occupational, educational, and emotional interruptions. Add to this the high stress of achieving social mobility for people starting from a lower societal standing, and the correlation between racism and depression starts to clarify itself.
Aside from MDD, there are five other types of depression. Crucially, one type, called Adjustment Disorder with a Depressive Mood, is triggered within three months of dealing with a major stressor. In this case, stress causes impaired functioning and can only repair when the stressor is removed, within six months.
But what if the stressor is never removed?
Here’s where we hop into the hard science: how can racism, which causes stress, lead to a sustained depressive state?
The Science of Stress
Stress differs from anxiety in one key aspect: anxiety is an internal reaction to stress, while stress itself is a response to a threat.
In fact, if we look at the definition of stress: a physical, chemical, or emotional factor that causes bodily or mental tension and may be a factor in disease causation (Merriam-Webster), we see that already, stress is understood as a factor in disease causation. But to take it a step further, a state of ‘being stressed’ is defined as “bodily or mental tension resulting from factors that…alter an existent state of equilibrium.”
In other words, stress can be a response to the threat of losing equilibrium, that at its most extreme, can lead to disease. If you live in a state of equilibrium at home or in a community where you are considered a full and equal person (such as an all-black school, or a diverse family), then naturally, the micro- and macro-aggressions racism presents in communities where you are not seen as equal register as stressors and trigger our body’s threat response.
If a lack of equality can cause mental tension, such that it’s a built-in function of even our language regarding stress, then how are our bodies manifesting this? And how does that manifestation cause depression?
The answer is in HPA.
Our body’s stress response system is finely tuned to help us guard against perceived dangers—in the internal ‘fight or flight’ motto; our brain hits the gas on ‘fight.’ And fight, for our brains, comes in the form of a hormone called corticotropin, which binds to receptors on the brain’s anterior pituitary gland, allowing for the released of ACTH: adrenocorticotropic hormones. ACTH then binds to adrenal cortex receptors and stimulates the release of something you may have heard of—cortisol, the feel-bad drug of the body. This everyday phenomenon, called Hypothalamic-Pituitary-Adrenal (HPA) axis deregulation, can be encouraged to stick around longer than we’d like it to.
The HPA stress response usually dissipates within a handful of hours, once the stressor that caused it is well behind us, overcome and forgotten by a long walk, a milkshake, or a Netflix binge-a-thon. But, what happens if someone cannot escape the stressor? What happens if, like racism, the stressor is a part of daily life? That’s when a problem occurs.
Humans can acclimate to higher levels of sustained HPA—which means that acute sensitivity to (and thus, our awareness of) a stressor will be lost, but the heightened levels of cortisol production remain intact. In other words, we perceive racism less, while responding to it constantly, even in diffuse situations. Once this occurs, one of the only ways to regulate cortisol levels back to normal rates is to remove the stressor—to obtain that elusive equilibrium back, for a sustained amount of time. To live in a community void of racism.
Young men and adult women are especially at risk of this cognitive shift—they naturally secrete higher base levels of cortisol. On the other end of the spectrum, humans are naturally less sensitive to cortisol as they age—so older adults who may perceive that they are ‘past’ racism or have ‘simply learned to cope with the way things are’ may actually just be producing less cortisol and also less epinephrine in response to racism. If epinephrine is the ‘get hype’ chemical of the body, then older generations are sitting the rave out.
The impacts of racism on the dysregulation of cognitive functions has also been noted across several studies. The chemical response to a heightened threat level affects brain regions including the anterior, prefrontal cortex, cingulate cortex, thalamus, and the amygdala—all of which play a significant role in the formation of depression. Similarly, neuroimaging studies on the correlation between racism and the state of the brain show that activation in parts of the brain involved in scenarios of extreme racism are the same parts which activate when humans are in physical pain. To the brain, these two circumstances are close cousins.
In several studies which have measured racism’s effect on physical, mental and general health, the largest negatively affected area has consistently been mental — with rates higher than two times more affected patients suffering mentally than physically due to racism.
In the compilation study, Racism as a Determinant of Health: A Systematic Review and Meta-Analysis (Ben, et al., 2015), all 293 studies conducted since 1983 on the relationship between racism and depression were parsed into metadata. And to be clear—between 1983 and 2013, there have only been 293 English-language studies and 33 published articles on this connection worldwide, despite overwhelming evidence and need. Before 1983, that number drops to zero.
This aggregate data showed an interesting trend, where races other than black were considered.
Namely, that in the U.S., the negative ‘harassment effect’ of racism was higher for LatinX and Asian Americans than it was for Americans or Native Americans. The higher rate of negative mental health outcomes for these groups could be for many reasons. For one, LatinX and Asian Americans generally live in closer-knit communities than other groups, more often drawn together by native languages outside of English, which may reduce incidences of experienced racism (the stress of lost equilibrium) within their communities—but may in contrast heighten it any time they step outside of these bounds, making experienced racism less constant, but thereby more traumatic and overt when this aggression is experienced. Racism also may qualify as less expected and more surprising based on how ‘white passing’ a minority member is. Racism, often, is a game of ‘shades,’ even within POC communities—those with darker skin bear a more overbearing form of racism, while those with lighter shades of skin—found more often in LatinX and Asian American communities than in black communities—may experience this racism less.
However, that would not explain the part of the data dealing with the Native American experience. But cortisol might.
Despite many Native Americans being ‘white passing’ or lighter skinned, and there being close-knit groupings of Native American communities (with 22 percent of the U.S.’s 5.2 million Native Americans living on tribal lands, according to the 2010 U.S. Census), Native American populations are simply more used to constant racism, in line with black communities. They face constant racism in media, in voter disenfranchisement, in the government misappropriation of Native lands, in the defunding of increasingly squalid reservations, in the use of their religious and ceremonial dress as costumes, in offensive lingual tradition (‘off the reservation’, ‘sit Indian style’), and the pervasive, proud cultural narrative of colonial domination that formed the U.S. In this way, it is not outlandish to suggest that Native Americans are also suffering from the same sustained levels of cortisol production associated with never living in a place of equality, or untouched by discrimination. The spikes we see in LatinX and Asian American communities when exposed to racism might belay cyclical visitations of discrimination, as opposed to sustained, internalized ones.
Still, the idea of studying minorities other than black in the context of their relationship to racism is a new one—there were only six studies on Native Americans at the time of publication, and only five on LatinX populations.
Nonetheless, science knows for a fact that life events are on par as a risk factor for depression, on the same scale as brain chemistry or personality. And the correlation between racism and negative mental health impact is evident, even beyond that. Irrespective of the methodology of several studies, all came to the same conclusion.
Racism is a major cause of depression.
So why aren’t we treating it like one?
“Racism is a pathogen that generates depression”
Can Medicine Itself Be… Racist?
The answer to that (you might be expecting it by now!) is a strong “Yep!”
Let’s look at the same compilation of studies again.
Out of the only 293 English-language studies done on racism and depression between 1983 and 2013, 81.4 percent were conducted in the U.S. These were studies on racism in general—not just focused on black communities, but any minority community. That number drops to a staggering 2.7 percent in the U.K., 2.1 percent in Canada, 2.7 percent in Australia, and only 0.6 percent took New Zealand’s diverse residents into account—all of these, countries with black minority populations, all with diverse racial demographics, and all with populations facing serious mental health crises.
If these study rates are astonishingly low, then it’s even more hair-raising to see how the numbers plummet when racial minority groups outside of black communities are considered. Very few studies and articles deal with LatinX, Arab, Indian, or ethnically Asian populations, and fewer still on recent migrant or aboriginal populations: such that the words “no significant data” echo through the blank pages of medical indexes.
In these studies, the most common negative mental health outcome of racism was MDD, ahead of self-esteem issues, psychological distress, and anxiety. This came with symptoms of hypertension, high blood pressure, heart conditions, and a higher body mass index (BMI). Poorer mental health from racism came ahead of poor physical health as an effect, but the two are inexorably tied together once depression settles in.
It’s difficult to contextualize an issue that there’s no background on, no firm statistics and correlations for. Countries like England, Scotland, Canada, and Australia are lagging, and this lag often takes the form of a dormant social consciousness. Without this narrative being a part of the social consciousness, it can’t effectively enter health care or even social dialogues. We cannot begin to understand what we have not even yet begun to formulate as an idea, but that doesn’t make it any less real or true.
If racism isn’t a foundational context for how we talk about depression, then it won’t be included in how we address and alleviate the problem. These gaps in study percentages, and the relative newness of these studies in general, betray a significant fissure in the global commitment to proving how discrimination can be a leading cause of negative mental health.
This might explain why there is so little cultural competence in mental health care today.
Only 16.5 percent of psychologists have minority identities in the U.S., according to the American Psychological Association (ACA)—and only 2 percent of these are black, with the number of black female members of the ACA outshining that of men. For black mental health patients, especially men, this means lowered trust in psychological science (and indeed, any historically white systems of power and influence), medication, and therapy, as therapists and doctors cannot relate to their specific set of traumas and stressors, and, have a higher rate of minimizing, misdiagnosing, or over-drugging black patients.
This medical racism is built into the education of therapists, even. Medical textbook definitions of depression and their manifestations are based on ‘Caucasian symptoms.’ The symptoms of a white person experiencing depression, however, may manifest very differently than in minorities facing depression caused by—or in addition to—racism.
This leads to higher rates of misdiagnosis. Because black Americans exhibiting symptoms of racism-based depression manifest symptoms of a different, and sometimes more severe sort, they are more likely to have their depression misdiagnosed as a physical condition, PTSD, or schizophrenia.
If the education side is failing POC, then the solution side can’t be doing much better. In fact, the over-prescribing of pills is a consequence of this lack of cultural competency. According to the National Alliance on Mental Illness, on average, patients with black ethnic backgrounds are less able to metabolize the current drugs on the market—perhaps because they were created with Caucasian physiology in mind. As a result, doctors tend to over-prescribe larger doses of drugs that ‘aren’t working as desired’ to black Americans, which adds to a stigma that black patients have more severe symptoms and are less curable or manageable. Similarly, higher dosages of medication—especially those not easily metabolized—may lead to worsening side effects, causing an avalanche of other health problems, or scaring patients off from medicating at all. In some cases, patients may take to self-medicating through substance abuse as a cheaper and more accessible option that ‘seems to work.’ Incarceration rates in U.S. prisons show that, as of 2011, black citizens were nearly seven times more likely than white ones to be given prison sentences for drug-related crime, with harsher sentencing, and you guessed it—even less access within the prison system to effective mental health care.
These are not the only obstacles racism places on the road to modern-day mental health recovery. According to the Journal of Health and Social Behavior, therapists themselves—who are often over-burdened with patient numbers—are more likely to fill open appointment slots with white middle-class applicants over black middle-class ones. This can often be accomplished just by looking at the names of perspective patients, and the bias may even be unconscious in some cases. The stigma goes deeper when the poverty line is considered: therapists are more likely to book middle-class POC over any race of working poor, including white patients. This is something they can judge based on health insurance tiers.
But this also affects POC. In the U.S., black Americans are 7.3 times more likely to live in poverty than whites. Black neighborhoods are also less likely to have the number of therapists that the community needs, having on average less than white neighborhoods do. And due to economic inequality, POC are less likely to be able to take off from work to see a therapist, less able to travel long distances to go to doctors, and less likely to have health insurance that covers therapy. The racism built into wage disparity and traditional neighborhood planning helps create a vicious cycle which sustains depression in black communities.
Key reasons for black Americans dropping out of therapy, or never entering, to begin with, include this lack of cultural competence, unconscious (and conscious) bias by healthcare professionals, misdiagnosis rates, and a lack of representation in health care staff.
Yet, POC are 20 percent more likely than whites to suffer from serious psychological distress—this statistic jumps to three times higher for those below the poverty line. POC are more likely to experience feelings of hopelessness or worthlessness, but are also more likely to understand that their specific issues will be misinterpreted by modern medicine. For example, a black man trying to explain the feelings that a recent microaggression gave him (possibly invisible to a white listener) may be classified as ‘being weak,’ or a black woman reporting the same thing may be seen as ‘sensitive and hysterical.’ No one wants to have to educate and convince a professional on how to take care of them and validate them. Even less so, if the professional looks like the perpetrator.
But what if, despite all of this, someone still just wants to get help? Well, then they might just have the stigma to deal with.
Stigma: “Can’t you just, like, go get HELP?”
With staggering statistics like this—16.2 million people in the U.S. alone suffering from depression, and an even higher percentage per population in the U.K.—how could there be any stigma? Depression is one of the most predominant mental health issues in the world, second to anxiety, and a leading cause of life under disability.
In 2009, a study was conducted by the Journal of Personality and Social Policy, titled, Racial Discrimination and the Stress Process. A total of 174 POC with PhDs or pursuing PhDs kept a daily diary of their interactions with racism; incidences of racism were reported, on average, on 26 percent of the total days. This study took a look at the most educated—and presumably, the (eventual) highest-earning black Americans—who nonetheless were experiencing racism in both subtle and overt forms. More subtle forms of racism that were recorded included being snubbed at work, unheeded in class, or denied services in stores. On days where racist incidences were reported, levels of depression and anxiety were higher for these scholars.
So, if even the most educated members of a community are struggling with this common mental illness and the thematic injustice of racism, why don’t more black Americans go out of their way to seek help?
According to the National Alliance on Mental Illness, only about 14 percent of black Americans seek mental healthcare when it is needed—as opposed to 40 percent of white patients who need it.
As discussed, key reasons behind this include a distrust of prejudiced medical practice, a lack of culturally competent therapists and doctors, and socioeconomic barriers—black Americans earn, on average, 25 percent less than what their white counterparts make in the same job roles, and this number can slump further for black women and queer POC. This means that expensive therapy sessions can sometimes not fit budgetary requirements, especially as 11.7 percent of black Americans don’t have access to health insurance. Compare that number to the U.S.’s white population (7.5 percent with no access), its Asian American population (6.3 percent with no access), or even the percentage of the black American community that was uninsured in 2013 (18.9 percent), before the Affordable Care Act stormed America’s political battlegrounds. That’s close to 8 million uninsured people.
And this isn’t just a U.S. phenomenon, unsurprisingly. According to the fourth National Survey of Ethnic Minorities in the U.K., British POC who suffered race-based verbal abuse were three times more likely to suffer from a depressive episode, yet still less likely than white peers to seek help for these episodes.
This comes down to pressure from both inside and outside ethnic communities. Outside the community, having to work twice as hard to be seen as equal to white peers is a self-flagellating game that racial minorities are forced to play. Any weakness or flaw can be an automatic game over, so POC are less likely to want to admit to depression on the chance it will be seen as an inevitable weakness or character flaw—as if they are too sensitive, over-reacting, angry and violent, or explosive. “Real men don’t cry. Stop complaining. Stop being such a girl.”
This experience is boiled down to something called John Henryism: an approach to coping with sustained stressors like racial discrimination by expending superhuman, prohibitive levels of effort. Over time, this amasses a number of negative physiological and psychological costs to the over-achiever. In the face of unbeatable odds, society tells POC that determination and hard work can elevate them. However, when both are exhaustively rendered, and when POC live according to the utmost standers of a society’s rules yet still experience racism, this exposes John Henryism as an unwinnable farce, and this can be devastating.
This is perhaps best illustrated by a figure mentioned earlier—that higher-earning adult POC are more likely to experience depressive symptoms. POC earning over $80,000 a year have higher incidences of depression than those earning under $17,000. Those in higher-earning settings are working many times harder than non-POC in the same settings to achieve the same elevated levels of salary and job placement, yet despite their salary, status, and perhaps level of education, they are still experiencing racism.
Stigma from within minority communities
Surprisingly, however, much of the stigma also comes from within minority communities.
Black men are particularly convinced that seeking help is a sign of weakness, and view admitting to depression as an unacceptable vulnerability. Hyper-masculinity demands that ‘real men’ deny troubles and fragility. This bravado is sometimes even necessary for survival in an antagonistic society. The weak are mocked and ostracized, by peers and enemies alike. However, psychiatric treatment as a whole is seen as somewhat taboo in POC communities.
In a series of outreach and interviews I conducted as a part of this article, I received feedback from POC in the mental health community which gave insights on the everyday stigma attached to depression in their own neighborhood and families.
“I was raised to ‘suck it up.’”
“There is a stigma in the [black American] community regarding depression and therapy that falls into the toxic masculinity category as well.”
“The Queer community is very supportive of self-care. [black American] communities…look down on it, and white communities tend to view it with a sort of soft disdain.”
“I do feel like black men are very against the idea of seeking help for mental issues…although as a mixed person, I feel as though I am cut some slack.”
Some interviewees also brought up the difference in stigma level determined by cultural background. For example, how Ugandan might parents react versus how Caribbean parents might react. In situations where POC are aware of the national identities and cultures of their families outside of American, British, and other identities, different cultural contexts will naturally come into play. This can be especially so for families with recent migrants of any cultural background, where the level of determination and gumption it took to move countries, learn a foreign language, and settle with a family into a new life makes migrant persons even less willing to show weakness, and in some cases, less understanding of the depression of their children, who have comparatively ‘cushy’ lives. Of course, for many POC, knowing the exact national and cultural lineage of their families is a distant privilege, robbed from them by slavery.
Another aspect of the stigma which Americans especially tend to shy away from discussing is religion. America is more pious than its thin separation of church and state might imply. And for black American communities, it can be central to how many decide to independently cope with depression.
According to the Pew Research Center, only 2 percent of the black population in the U.S. reported they do not believe in God. This is the lowest percentage of any racial or ethnic group in the United States, and only 9 percent of the overall black population reported that they are not a member of a religion. Black Americans also rate the importance of religion in their everyday lives at the highest percentage of any ethnic population in the U.S., at 75 percent. Comparatively, the next highest percentage are LatinX people (dropping to 59 percent), followed by mixed-race (54 percent), white (49 percent), and then Asian Americans (36 percent). Black Americans have the highest attendance rates for worship services, the highest rate of daily prayer, and importantly, the highest rate of being guided between what is right versus wrong based on religious text.
While there is nothing inherently wrong with religious devotion, faith, or belief in God, up to two-thirds of black Americans have reported feeling that their depression can be cured through devotion to God, prayer, and meditation alone, according to the National Alliance for the Mentally Ill. And while it isn’t wrong to center and nurture in this way, depression remains a disease—it is no easier to pray away than cancer, and failing to beat cancer on one’s own is not a sign of a lack of devotion any more than failing to beat depression is. Being unable to alleviate depression through prayer can lead to further feelings of depression—the sensation that admitting to depression means the religious person was not zealous enough, or not loved enough by God, which can further feelings of worthlessness and guilt. Religion, misused in this way, can be a powerful stigma—and it affects many black communities in America.
Stigma also plays differently across state lines. Fifty-five percent of all POC-reported depression comes from the southern U.S. states, where unsurprisingly, historical factors such as the history of slavery, Confederate pride, and sustained elements of segregation lead to a more aggressive landscape for black Americans. By contrast, only 17 percent of POC-reported depression comes from northeastern states, where major cities have large black populations—New York ranks as having the highest population of black Americans, with Philadelphia coming in third. Of the top ten most POC-populated cities, four are in the Northeast—only two are in the South. This can speak again to the fact that communities with significantly higher white populations (compared to cities with diverse populations) have higher rates of racism-based negative mental health outcomes.
There is also a strong culture of ‘avoidant coping’ in black communities: the notion that it is better to ignore, suppress, or replace upsetting emotions with false confidence, outward acts of self-esteem, or rigorous optimism in order to keep functioning—that admitting to depression would cause everything to crumble, but that by avoiding admitting to it, you also avoid creating havoc. “Keep calm and carry on.”
The issue with avoidant coping is it ultimately makes emotional reactions to stressors stronger, and eventually leads to a steeper crash. Part of this avoidance, which makes it particularly destructive to lives, isn’t just emotional, but literal—avoiding social events where stressors might be present, or even skipping school and work to avoid racial microaggressions that may break down the positive fantasy. In most cases, avoiding places where racism may occur means avoiding most places.
Microaggressions themselves are another piece of the stigma puzzle. Difficult to explain and elusive in nature, they are like stepping on a social landmine—the more acclimated to them you become, the more you think you’re about to step on one. If a barista calls the name of the person who was behind you in line first to come get their drink, and they are white, and you are black—is this just an accident, or a microaggression? Was their drink easier to make then yours? What about when this happens a dozen times—a hundred? Then, the line between accident and racism starts to blur on every single occasion.
Explaining these microaggressions, which are often brushed aside as “no big deal” or unintentional by non-POC, can feel very isolating and de-legitimizing, and encourages minorities not to bring them up for fear their concerns will be ridiculed rather than validated. Microaggressions are indirect slights and subtle denigrations which infer defectiveness or insignificance. These microaggressions can be direct actions, or represented in actual sectors of socioeconomic life, like a lack of representation in education (in professorial staff, in AP student classes), in government (mostly-white representatives), in media (where POC are rarely the heroes unless the film is all-POC), and in general disenfranchisement.
Lastly, more overt racism in the form of verbal harassment, abusive language, physical violence, or unwelcoming spaces create a sense of racial ‘battle exhaustion.’ This manifests as the idea that POC have no control to change their situation (resulting in a loss of interest to try), the idea that they are incapable of ‘adding value.’ They may even internalize and perpetuate their own perceived inferiority in communities where that is the dominant cultural narrative, in order to fit in.
Perceptions of control are vital to a mental health narrative. If hopelessness is an opposite of control, then hopeless people don’t see the point in wasting time, money, and social face in order to pursue an elusive solution which may not exist for them. As POC and other minority groups have no control over when and where they will experience racism, this lack of jurisdiction over their own lives becomes exported to other aspects of their identity. Everything becomes a ticking time bomb. Feeling that one lacks added value means that minority peoples who give their best effort, only to have their personhood continually called into question, will begin to feel invisible, disposable, and will slowly stop sharpening talents and acquiring new skills. When even the right to live safely is constantly in flux, then learning lacrosse, violin, or coding may start to feel pointless.
Internalized racism leads to more critical self-evaluations that skew more and more negative over time, into a cultural subservience then cemented by dominant societal representations. One example of this is in the 1947 Doll Test, where both black and white children had a preference for white dolls. In more recent studies, the preference for white over black skin in black communities has lessened with better representation in toys, media, and education, but the preference for lighter still exists. And even this can be a stigma for members of the black community—lighter-skinned POC often report feeling that perhaps their achievements are attributed to their having lighter skin, and that they must prove themselves worthy to both white people and to darker members of their community. This guilt complex is also reported by many white-passing mixed-race people.
Racism—and racial discrimination—as a social structure is a lot to untangle. Which means, it might be time to ask the everyday experts: those experiencing racism.
Community Voices: Stories from Society
As a part of this story, I felt it was important to reach out to black communities in the U.S. for feedback, to amplify their thoughts, voices, fears, and feelings. It would be a mistake to speak over the very group being represented.
While the below data does not represent an aggregate, it can clue us into some important trends. This brand of informal outreach was imperative, because while science might dictate the facts, it is human stories which make those facts real, relatable, and impactful—and it is human truth which clued science in in the first place. Giving POC and minorities a platform to speak for themselves is one of the key steps to understanding discrimination and legitimizing its universality for certain groups.
During outreach, words like “microaggressions” and “insidious racism” continually popped up, often alongside the idea that less overt racism is often the most difficult to cope with. Other common buzzwords included “toxic masculinity” and “oppression dynamics”, which pointed towards a wide understanding that men are especially less likely to seek help in mental health spheres, and that secondary and tertiary minority identities piled onto being a racial minority (such as being LGBTQIA+, a religious minority, female, etc.) can sometimes further complicate the set of stressors one has to cope with.
Another point brought up, not yet considered by research, was that being treated as special and unique for being black was equally “othering,” and nearly as horrible and alienating as racism itself. That when white communities, coworkers, or educators try to shine a positive spotlight on a black person for their blackness, rather than for their talents and abilities, it is dehumanizing rather than uplifting. Being highlighted was just as bad as being erased when it was based on an unalterable hereditary reality.
Of prominent trend in these discussions was the fact that the majority of black community members had not given any thought to racism as a factor in their depression. However, after having the notion presented, every single person responded by agreeing it was a factor in their current or past depression. On average, people who shared their stories felt that racism was over 50 percent responsible for causing, worsening, or affecting their depression. Females felt this more acutely than males.
This is, in part, why putting the conversation out there matters so much—because if we do not even consider racism as a cause of depression, then we will never be able to treat many sufferers fully, consciously, and to the best of the mental health field’s ability.
During outreach, stories mainly corroborated one another. Here is a selection of responses representing POC and mixed-race voices in America.
“[White people] wanting me to validate them ‘not seeing color.’ Oh, please!”
“Racism which isn’t overt is more insidious… I find I come up with various, and increasingly ridiculous, excuses for racist behavior.”
“As someone who is white-passing, I feel the role my queerness plays in oppression dynamics more than my race [does]. But I do hear the microaggressions constantly when I’m in white circles and am perceived as white… not directed at me, [but which still cause] anxiety, rage, and depression.”
“There’s also this phenomenon of the oppressed taking on the behaviors of their oppressors within their own communities and turning those toxic behaviors inward to further divide. Mixed people like myself tend to be caught in the middle of that dynamic, with no community really wanting or fully trusting us.”
“I must work harder for acceptance rather than being [immediately] seen as equal. …Mixed individuals [like me, become]… the ‘ethnic’ friend to white friends, and the white friends to [POC], and it’s rare to be immediately accepted… We want to be accepted by both our sides without having to prove ourselves.”
“I certainly feel the pressure of working twice as hard for half the recognition. It affects how long I work, and I get guilted into working longer.”
“[Everyday racism has meant] I prefer to shop online, because I don’t like the look I get when I walk into a store. It also prevents any anxiety about being followed around [in the store].”
So, Beyond the Obvious, What Are the Solutions?
Step one to solving an issue is realizing we have one.
‘Racism just shouldn’t exist’ seems like a pretty easy and obvious (we hope) thing to say, but almost impossible to enact broadly. However, racism as a factor in depression is a reality we can do better to explore. Doing so will also help us see how inequality manifests itself into a vicious circle—how a more threatening world leads to lower test scores, lower pay, less ability to cope, which is then blamed back on the affected populations. First, it is imperative for everyone to understand that people living in the same community as themselves may see a much more intimidating landscape when they step outside due to their identity, and that these people go through life on a higher threat-level alert daily. By acknowledging the racist elephant in the room, we can knock the power out of it. Acknowledgement in place of minimization is the first step.
As The Anxiety and Depression Association of America reports, we can also practice more ‘deliberate compassion’ in mental health care—validations of feelings of rage, indignance and grief in response to racism, and justified annoyance when doctors simply don’t get it. By bolstering further studies of links between discrimination and negative mental health and publishing them widely so people and communities can arm themselves with pertinent knowledge and enter therapy with germane questions. A demand for better access to cultural competence learning by doctors, and encouragement of all minority groups and especially POC to enter mental health fields in greater numbers—their skills are sorely, demonstrably needed.
We can also use this information to begin to export the model of stressor-based depression to other minority identities to improve health care.
There is so much currently lacking in our understanding of how discrimination affects the mental health of LGBTQIA+ peoples, religious minorities, recent migrants, mixed race and other minority identities, the very poor, the homeless, the physically disabled, and ESL learners. Yet, connectivity models built on research done with POC could be exported easily to expand data on these identities, and the strength of corollary studies should encourage further investigation into other oppressed groups. Think of it this way—the World Health Organization only ceased calling homosexuality a mental disorder in 1992; the APA voted it out in 1973 by a gloomy margin. When your very identity is considered a disorder, it doesn’t encourage trust in the mental health care system. Medicine can, and needs to, do better for POC—but also other minorities.
Consider that the sub-group with the highest suicide rates in the U.S. is actually ethnically Asian American women—not only due to racism, but due to the hyper-sexualization and fetishization of Asian women in American media and culture. Or the fact that in the few studies on LatinX populations in the U.S., all found that LatinX people have the same triggers for depressive spikes as black Americans when it comes to racism. Or that when it comes to women, they are much more likely than men to manifest anxiety and panic disorder symptoms alongside their depression. Or, that when it comes to victims of rape, men are much more likely to have symptoms of PTSD—in 65 percent of cases, compared to 45.9 percent in women. In many ways, that statistic mimics the one about Native and black Americans being less shocked by incidences of racism than LatinX or Asian American populations—groups who live with a more pervasive threat of violence may be more likely to adjust to it before it even occurs, as they have been preparing for it their whole lives.
By exporting this model, we can have more comprehensive empathy and more exacting solutions for identities across the board. No two minds are alike; no two lives are alike. So mental health cannot and should not be a one-size-fits-all.
Another actionable solution is self-accountability—deciding today will be the day you won’t say “I am just fine” when you actually aren’t. Knowing when to say, “I’m not okay,” and knowing that it’s acceptable to not be okay. Normalizing the expectation that during stressful situations and instances of discrimination or oppression, it’s actually correct to not to be okay—to get angry, to get loud, or to cry. We must encourage the acknowledgement of true emotions, as they are felt. Ignoring them only creates a Catch-22, which heightens the intensity of our internal emotional responses while externally giving discriminatory or heinous behavior ‘a pass.’ This can lead to episodes of ‘blowing up’—which for minority groups leads to a vulgar cycle that gives false precedent to racist and misogynistic caricatures. That POC are somehow naturally angrier than whites (the parody of the angry black woman), or that women are “always whining” and “too emotional,” or that LGBTQIA+ folx are “so dramatic.” We too often say, “She is so angry,” rather than asking, “Why is she so angry?” And rarer still do we say, “That anger is so justified. I’d be angry, too.”
Normalize emotions. Understand that they are natural. We get angry over our latte order being wrong, over our train being late, over our boss being short with us, and we aren’t embarrassed to share this in CAPSLOCK tweets or badly auto-corrected texts. So why should we be embarrassed when discrimination makes us angry? Is it less serious than a bad latte? We need to acknowledge that the body’s natural response to danger is fear. That the body’s natural response to not having its needs met is anger. That the body’s natural response to feeling valueless or directionless is sadness. Communities that validate these feelings and experiences without letting them be internalized or judged give us our best chance of getting healthy as a global community.
Another great solution is to support or visit your local, minority-run therapy and meditation spaces. If there is not one local to your community, there are many online now, and online therapy appointments can alleviate some of the burdens of scheduling and travel. Some great examples of POC-run spaces are HealHaus, a male POC-focused health center that de-stigmatizes the mental health journey for men in New York City with compassion at the forefront; or Self-Care Check-In, an online space where you can track your progress, connect to helpers, and have the space to shout that you are not okay, when it’s one of those days.
Lastly, we need to remember that depression is a disease. If we don’t give NSAIDs to arthritis patients and then ask them to do heavy lifting, would we be surprised if they couldn’t do it, or if doing it caused them extreme physical pain and caused lasting damage? I’d hope not. Similarly, we cannot treat depression with pills and therapy alone while leaving an underpinning primary cause intact, to flourish—lurking, undiscussed, and unnoticed, a vigilant roadblock on the route to recovery for so many people in vulnerable groups. We need to treat racism as a key cause of the disease.
Share more stories of discrimination. Give these voices a platform. Take time to hear these stories, so people can see the commonality of them. Amplify. Validate. With so many voices chiming that we live in a ‘post-racial society,’ we must put dynamite to this myth, especially in the mental health sector where the absolute contrary is true. Race can be an uncomfortable topic. But more importantly, racism is an uncomfortable truth—and the discomfort is on the part of the people experiencing it. Those feelings should come before our discomfort with looking the truth in the eye.
Remember, we can only treat an issue when we recognize its symptoms as symptoms. And as noted by the International Journal of Social Psychiatry, “Racism is a pathogen that generates depression.”
So next time someone says racism is depressing, remind them that they mean it literally.