Interpreting Language Used By Older African Americans to Describe Depression in Light of DSM Criteria

Background and Purpose: Depression in late life is associated with substantial suffering, disability, suicide risk, and decreased health-related quality of life. The rate of misdiagnosis of depression is higher among African Americans; though, the reasons for this are not clear. The Diagnostic and Statistical Manual (DSM) is used to determine how a diagnosis of depression is made, based on a constellation of symptoms. Members of marginalized groups may describe symptoms differently and the DSM language may be inadequate for capturing these symptoms between different race and gender groups. The purpose of this study was (1) to examine the language used by older, church-going African American men and women when discussing depression and depression treatment and (2) to assess how this language compared to that of the DSM.

Methods: Focus groups with older, church-going African American men and women (n=50) were used to ascertain a deeper understanding of the language they use to describe depression. The study team employed several stages of coding and identified segments of raw text that were compared and analyzed for embedded meaning. Expressive identifiers were attached to this text and then these identifiers were used to identify categories, concepts, and themes important to the study goals and objectives. The study team worked individually, then collectively to identify relevant and emerging concepts and terminologies that were used by the older, church-going African American sample to discuss depression. This language was then mapped onto the depression criteria of the DSM.

Results: Focus group participants described depression in a variety of ways, and similarities were found across the male and female groups. For example, depression was described using terminology from the DSM as well as other, alternate symptoms that were synonyms for depressive mood symptoms.  Generally, the language used by participants focused on possible causes of depression and its impact on functionality, more so than the symptoms themselves.  In our interpretation of the results, we were careful to consider the DSM criteria, which focus on a constellation of symptoms. These symptoms include mood symptoms like sadness, and anhedonia; somatic symptoms like fatigue, psychomotor, sleep and appetite changes; and cognitive symptoms like guilt, worthlessness, poor concentration and thoughts of death. Some words used by the participants mapped well onto the DSM, while others did not. Several symptoms were discussed more frequently than others. These symptoms were sadness, fatigue and psychomotor changes, worthlessness and guilt, poor concentration, and thoughts of death.

Conclusions and Implications: Implications include the advantages of using qualitative data to help inform clinical encounters with older African Americans. The focus group setting provided insight to the language used by church-going African Americans to describe depression and how this can be further explored to aid in diagnosis of depression in African Americans, and improve early diagnosis, formal treatment, and reduce the severity of symptoms previously documented among older African Americans, both in the church and in the community as a whole.