Since becoming a primary care physician over 20 years ago, I made the conscious choice to cement my career treating black and minority patients, primarily in underserved and indigent communities. This career arc spans from rural clinics treating migrant farm workers to predominately black, inner-city hospitals. And while the reports of the overmedication of America might be true, when it comes to mental health issues, it is my experience that patients in black communities are under-medicated.
Over the years, I’ve learned that treating black patients comes with a unique set of challenges that requires a combination of medical knowledge, intuition and experience. It’s not uncommon for visits to have a good deal of emotional overlay. Common conditions are sometimes more severe or complicated when treatment is hampered by lack of funds, limited access to transportation, maybe limited literacy. Sometimes patients just seem not to comply. They don’t take medicines regularly, don’t check blood sugars, eat poorly. When pressed, they often don’t know why. They say: “I need to do better” or “I take care of others and forget about myself.”
One of the most frequent obstacles faced by health care professionals is that black patients are sometimes reluctant to acknowledge mental health issues and will often resist medicinal treatment for commonplace psychiatric, psychological and mental health issues. To be clear, I am not saying that blackness is a pathology that manifests itself in African American patients. But I can, however, imagine that some doctors might struggle to decipher these subtle clues if they aren’t as familiar with (or invested in) serving this constituency of patients.
Black patients are 20 percent more likely to report serious psychological distress than adult whites; African Americans living below poverty are three times more likely to report serious psychological distress than those living above poverty. Yet a 2003 study shows that black patients are less willing to use psychiatric medications than their white counterparts or administer them to a child in their care, even when they have equal access. Instead, black patients are known to self-medicate and address their mental health issues with alcohol, illegal substances and even religion.
Aside from a lack of diversity, experts say that this is possibly due to a lack of cultural competence in the fields of health care and psychiatry. For instance, patients frequently complain to me that they have “bad nerves,” which can sound very nebulous and unspecific. But with some prompting, they will go on to describe anxiety, irritability, insomnia and—very often— a desire to isolate themselves. Sometimes they are tearful, describing losses, fears, persistent stressors. They recount reactions to these issues that sometimes lead to problems with family, relationships, even legal problems.
A lot of patients are resistant to antidepressants and anxiolytics (anti-anxiety meds) that are taken daily. Instead of prevention, they prefer to treat extremes as they occur. It’s much harder to explain that anxiety, irritability or insomnia can possibly be signs of an underlying disease— depression—than it is to tie together chest pain and shortness of breath as possible signs of a heart condition.
“I’m not crazy” is something that I often hear because there is a stigma attached to anxiety, as opposed to panic attacks and PTSD. It is extremely rare that a patient describes their symptoms as “depression,” even when all of the clinical markers are present. Black men, in particular, are resistant to diagnoses of depression and are much less likely to go to therapy. Research by the National Institutes of Health indicates that African American males are more resistant to treatment for Major Depressive Disorder and are less likely to be diagnosed.
A combination of a lack of trust in the medical industry, folklore and historical or generational precedent can lead to leeriness about taking prescription medication, especially as it relates to mental health. I have quite a few patients who, with some prodding, will reluctantly try medicinal therapies like selective serotonin reuptake inhibitors (SSRIs), a first-line treatment for depression. But, compared to the number who would likely benefit from diagnoses, medication and counseling, the number is low. Aside from expertise and knowledge, trust and familiarity can play a major role in a patient’s willingness to adhere to their doctor’s orders.
When we talk about these medical problems, we tend to focus on traditional mental health issues like clinical depression and anxiety. But factors such as stress and PTSD can negatively affect a patient’s body and their ability to manage their medical conditions as much as diet and exercise. Not all of these patients are clinically depressed, but feeling stressed and overwhelmed is not usually taken as a sign of depression or anxiety. Yet, these problems can usually be treated with medication and therapy.
Doctors like myself must not only familiarize themselves with the medical conditions that affect their patients, they must also understand the personal and cultural challenges that might prevent patients from addressing these issues. An antidepressant that causes slight drowsiness may work well for a stay-at-home housewife, but a single mother working two jobs might eventually stop taking the prescription, making her more reluctant to try antidepressants in the future.
Ultimately, the brain is an organ and when it dysfunctions, we must recognize that there are treatments that exist, just as there are medicines that help our hearts or kidneys function properly. We must eliminate the stigma against treating our mental health issues, whether with therapy or prescribed medications, that can—and do—help.