Social Determinants Affecting Major Depressive Disorder Diagnostic Accuracy for African American Men
Research shows that depressed African American men are under-diagnosed with major depressive disorder. One reason for under-diagnosis is that social determinants may influence depressive symptom presentation. Symptom expression is a complex issue affected by the interplay of a number of factors such as race, class, and gender. Because of these social determinants, African American male clients may differ slightly in their expression of depressive psychopathology, when compared to other groups.
Clients can meet five or more of the nine criteria for a major depressive disorder as stated in the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) and yet still exhibit symptoms that are not considered “classic” symptoms. For instance, African American men may be less verbal in expressing sadness, they may show more irritability, and they may exhibit more insomnia rather than hypersomnia. This paper fills a gap in the literature by examining the ability of licensed mental health clinicians to assess depression in African American men when depression symptoms are influenced by social determinants.
Methods:
A random sample of 218 California Licensed Clinical Social Workers (LCSWs) and Licensed Marriage and Family Therapists (LMFTs) were randomly assigned to experimentally designed clinical videos via website and asked to make diagnostic judgments. The videos portrayed a “first-time mental health client” who presented with either “classic” depressive symptoms or a depression presentation affected by social determinants noted in the literature. The clinician sample is predominantly female (77%), White (84% White; 7% Hispanic; 4% Asian; 1% Black), and middle-aged (mean age was 53, SD = 29-80). More clinicians were LCSWs than LMFTs (59% LCSWs), and 38% had more than 20 years of licensed experience. This analysis examined the open-ended information that each clinician wrote during the survey process about why they chose the particular diagnosis they did for the client in the video they watched. Open ended data was downloaded verbatim via Excel spreadsheet into Atlas.ti qualitative software, and the data was coded thematically through an inductive process (content analysis).
Findings:
Clinicians presented with videos of a male client with depression symptoms influenced by social determinants were less accurate in their diagnoses than clinicians presented with videos of a depressed male client expressing “classic” depression symptoms. Statements clinicians made about their diagnoses revealed that clinicians often saw culturally influenced depression symptoms as behavioral disorder-related symptoms or personality disorder-related symptoms rather than mood disorder-related symptoms. The data suggests that when faced with symptoms influenced by social determinants, clinicians may be influenced by the perceived lack of “cooperativeness” of a client and then provide diagnoses that have less empathy attached to them (such as conduct disorder, borderline personality disorder, etc.).
Conclusion and Implications
These findings are in line with other studies that have determined the under diagnosis of depression in African Americans, but the findings shed light on the thought process that some clinicians go through when interpreting symptoms that are not “classic” depression symptoms. Based on these results, best practice recommendations are presented for clinicians who assess depressed African American men.