By Krista Cezair
To begin to address these disparities, I suggest building on the recent proposal drafted by the United States Preventive Services Task Force (USPSTF), which calls for primary care physicians to screen all adults aged 64 years or younger, including pregnant and postpartum persons, for anxiety disorders as part of their routine care.
In this article, I suggest that mental health screening for Black women should include screening for depression in addition to anxiety. The universal nature of these proposed anxiety and depression screenings would be especially helpful for Black women, who may be inhibited from seeking mental health treatment by the Strong Black Woman (SBW) stereotype and other cultural factors.
It is important to note that screening does not diagnose a patient; rather, it indicates that further assessment and care are needed. For this proposal to yield true benefits, screening should be followed by diagnostic assessment when indicated. Most importantly, barriers to accessing mental health care post-screening/diagnosis should be addressed, such that patients can easily and affordably receive treatment.
How would Black women benefit from more ubiquitous screening?
Black women who experience psychological distress, as a group, tend to fall into the underserved category of people whose depression and anxiety are not noticed by providers and who do not seek treatment themselves. There are several reasons for this.
Cultural reasons include exposure to stigma, stereotypes and the SBW schema, and Black women’s unique stressors due to intersectional systems of oppression. The SBW schema and the Superwoman schema (SWS) are cultural expectations of Black women that project images of strength, lack of vulnerability, less need for care and support, and a focus on caregiving onto them. Given these expectations, asking for help is strongly discouraged, especially seeking help for psychological distress, which is expected to be managed on one’s own.
The USPSTF guideline works to provide mental health assistance with less stigma, because Black women would not be singled out; the guideline calls for all adults to receive the anxiety screening. Even my suggestion for Black women to receive additional depression screening does not treat any one Black woman as different.
By screening all adults for anxiety and all Black women for depression, we offer care to Black women without forcing them to speak up and ask for it themselves, an incredibly difficult thing to do. Just by asking in an open framework about mental health and neutralizing the self- and other stigma by saying that all patients are asked about this, we can reduce disparities in screening and perhaps further diagnosis.
Treatment is another matter altogether, considering that anxiety’s median age of onset is 11 years but the median time to treatment initiation is two decades later. When Black women do access treatment, they tend to do so when their symptoms are more severe and are impairing their functioning. Catching Black women’s symptoms early could help to connect them to mental health treatment before they experience a major episode. This is especially important because Black people are often misdiagnosed with psychotic disorders when presenting with affective or mood disorders, like depression. Such misdiagnosis can trigger a chain of negative experiences with and mistrust of the entire apparatus of mental health care.
Are there downsides to providing depression screening for Black women?
The most common reason that people with an unmet need for mental health care go without it is that they cannot afford the cost of care, according to a national survey conducted by the Substance Abuse and Mental Health Services Administration. By screening all patients for mental health concerns, patients may be informed of a need for mental health treatment but lack the resources or access to the necessary services. Accordingly, for a comprehensive screening program to provide real benefits to patients, follow-up services must be affordable and accessible as well. Currently, one major barrier to mental health care is insurance coverage. Whereas 90 percent of general health care is paid for by insurance coverage, only 45 percent of psychiatrists accept insurance. This represents a significant financial barrier to access to care. There is also a chronic shortage of mental health care providers that could become even more pronounced if more people are recommended for treatment; there already are not enough mental health specialists to meet the current increased demand brought on by the mental health crisis exacerbated by the COVID-19 pandemic
Other criticisms of widespread screening focus on the high number of false positives that might result, the overtreatment of mild symptoms that would not have needed formal intervention, and the diversion of resources away from people who truly need help. Some researchers and physicians advise that primary care doctors should just be aware of the potential of depression in their patients. But Black women are currently being failed by the health care system by this approach.
Black women stand to gain from the universal screening guidelines as written, and could gain even more if they were given the extra attention of depression screenings in primary care, but only if affordable mental health care is made available for follow up. These recommendations should be put into practice in tandem with comprehensive reform to the mental health care system such that follow-up care is made affordable and widely available.
Krista Cezair is a graduate student earning a dual JD/MPH at Harvard Law School and the Harvard T.H. Chan School of Public Health, working toward concentrations in Health Policy and Population Mental Health.