Inclusion and Exclusion Criteria

Eligible studies included those focused predominantly on African American men and Black men as well as those that separated the analysis by race and ethnicity. In some cases, studies with a sample of both African American men and women were included if the analysis was separated by gender. A diagnosis of depression according to standardized Diagnostic and Statistical Manual of Mental Disorders—DSM-III and DSM-IV criteria was necessary for inclusion (3rd ed.; DSM-III; American Psychiatric Association, [APA], 1980; 4th ed.; DSM-IV; APA, 1994). Since the DSM-IV was published in 1994 and studies conducted before 1994 were included in this review, the DSM-III criteria also needed to be considered. All empirical studies included in this review (see Table 1) were published between 1984 and 2009. This time period was used to provide a synthesis of literature focusing on depression among African American men in the past 25 years. Findings from the present review were intended to inform discussion about implications for future research and clinical practice specific to African American men. Thus, studies that did not separate the analysis by race, ethnicity, and gender were excluded. Additionally, unpublished dissertations listed in Dissertation Abstracts International, studies focusing on HIV/AIDS, cardiovascular disease, smoking cessation, homeless men, and incarcerated men were excluded. Unpublished dissertations were not included because of the difficulty accessing them, and they are not peer reviewed. Also, articles focusing on other health conditions were excluded, as the purpose of the present review was to focus specifically on major depressive disorders among African American men.

Search Strategies and Scoring System

An extensive literature search was conducted using the following strategies: electronic searches: Academic Search, ERIC, Psych INFO, Social Sciences full text, PubMed, CINAHL, MEDLINE Plus, and COCHRANE Library. Medical subject headings (MeSH) categories entered singly and in combination were depression, depressive disorder, African American men, and Black men. Manual searching was used to identify references in articles found from electronic searches and to locate these articles in Web of Knowledge. Titles and abstracts were reviewed, and articles meeting inclusion criteria were retrieved and reviewed.

An objective scoring system, adapted from the Jadad criteria to reduce article selection bias, helped determine which articles met inclusion criteria (Jadad et al., 1996). Using the adapted Jadad scoring system, each study was rated for eligibility. The scoring system included the dimensions listed below, which were scored from 0 to 5 (5 being the best quality).

• Study conducted in the United States and article published in English.

• Hypotheses or research questions and objective of the study clearly stated.

• Patient population described—sociodemographic information (i.e., age, gender, race, ethnicity, socioeconomic status, and mental health diagnoses, i.e., major depressive disorder and depression symptoms).

• Data analyses separated by race and ethnicity allowed differential implications for depression in African American men to be determined.

• Study design (i.e., quantitative: randomized clinical trial, observational, case series, and qualitative); study procedures (i.e., data collection methods and length of study).

• Outcome measures (i.e., Center for Epidemiological Studies Depression Scale, Beck Depression Inventory, or Hamilton Depression Rating Scale).

• Results—Data collected and analyzed according to each hypothesis or research question, and study results were presented specific to African American men.

The initial literature search yielded 120 empirical studies focusing on depression and including African American (Black) men in the sample. Nineteen empirical studies remained after eliminating studies that did not meet our inclusion criteria (see Figure 1 and Table 1). As mentioned earlier, 19 empirical studies focusing on depression among African American men were identified in a 25-year time span (1985–2010). These 19 articles were reviewed and analyzed to obtain the following information for this present review: (a) the prevalence of depression among African American men, (b) risk factors unique to African American men, (c) treatment-seeking behaviors unique to African American men, and (d) barriers to treatment seeking among African American men.

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Figure 1

Flow diagram of study inclusion.

Sample Characteristics

All 19 of the studies included in the present review samples included African American and Caucasian men. Some of the study samples also included Black Caribbean, Hispanic, and Asian men. Demographic information from all of these studies resulted in a total of 130,241 participants, of which 8,833 participants were African American men. Participants’ ages ranged from 18 to 65 years and older. Socioeconomic status varied, with the majority of African American male participants in the lower socioeconomic status.

Prevalence of Major Depressive Disorder and Depressive Symptoms Among African American Men

Three national survey studies and one regional survey study were found documenting the prevalence of major depressive disorder (MDD) among African American men. Prevalence estimates ranged from 5% to 10% (Compton, Conway, Stinson, & Grant 2006; Lincoln, Taylor, Watkins, & Chatters 2011; Skarupski et al., 2005; Williams et al., 2007). Compton et al. examined changes in the prevalence of major depression between 1991–1992 and 2001–2002 and whether changes in depression rates were associated with changes in rates of comorbid substance use disorder. Data were drawn from the National Longitudinal Alcohol Epidemiologic Survey (N = 42,862, n = 3,062 African Americans) and the National Epidemiologic Survey on Alcohol and Related Conditions (N = 43,093, n = 8,245 African Americans) totaling a sample of 85,955, of whom 11,307 were African Americans (Grant & Dawson, 1997; Grant et al., 2004). The Compton study results indicated the prevalence of major depression among U.S. adults increased that from 3.33% to 7.06% from 1991–1992 to 2001–2002, and statistically significant increases were evident among Whites, Blacks, and Hispanics. Among Black men, the prevalence of depression increased from 2.48% to 6.48%. Results also showed that depression comorbid with substance use disorder among U.S. adults increased from 9.97% to 15.06%. Among Black men, the prevalence of depression comorbid with substance use disorders increased from 7.36% to 15.55%, and a particularly concerning increase was found for young Black men (age 18–29), with rate increases from 9.49% to 21.34%.

In another national survey with a representative sample of African American men, Williams et al. (2007) examined the prevalence, persistence, treatment, and disability associated with MDD in African Americans, Caribbean Blacks, and non-Hispanic Whites. Data were drawn from the National Survey of American Life: Coping with Stress in the 21st Century (NSAL), with a total study sample of 6,082 adults, of whom 1,271 were African American men. Results indicated that the lifetime prevalence estimates of MDD were highest for Whites (17.9%), followed by Caribbean Blacks (12.9%), African Americans (10.4%), and African American men (7%). Although the lifetime prevalence of MDD was lowest for African Americans, including African American men, African Americans (56.5%), along with Caribbean Blacks (56.0%), evidenced higher chronicity and disability compared with Whites (38.6%). Further examination of the chronicity and disability associated with MDD showed severe role impairment in areas of work (Blacks 37.2%, Whites 28.9%), relationship (Blacks 43.2%, Whites 30.9%), and social (Blacks 55.4%, Whites 34.2%). In another study using the NSAL data set, Lincoln et al. (2011) examined the 12-month and lifetime prevalence of MDD among African American men. Results showed a 12-month prevalence of 5.02% and lifetime prevalence of 9.98%, which was slightly higher than the lifetime prevalence in the Williams et al. (2007) study. However, the Lincoln et al. (2011) study did not include examining chronicity and disability patterns among participants.

In one of the only two studies in the present review that included older African American men, Skarupski et al. (2005) examined racial differences in depressive symptoms among older adults over time. Data were drawn from the Chicago Health and Aging Project (CHAP), which is a longitudinal, population-based study of risk factors for Alzheimer’s disease and other age-related chronic conditions among community-dwelling adults aged 65 and older. The total sample consisted of 6,158 individuals, of whom 1,034 were African American men. Overall, older Blacks reported a higher prevalence of depression symptoms than did Whites. Although Black women had the highest prevalence of depression symptoms at each of the three time points (1993–1997; 1997–2000; 2000–2003), older Black men at each time point had a higher prevalence of depression symptoms (11.2, 20.9, 15.9) compared with older White men (6.5, 8.5, 5.5).

Risk Factors for Depression Among African American Men

Thirteen studies were identified that met inclusion criteria for the present review focusing on risk factors for MDD among African American men. Of these studies, two focused on the role of discrimination as a potential risk factor for depression among African American men. In particular, one study (Banks, Kohn-Wood, & Spencer, 2006) examined the association between discrimination and specific anxiety and depressive symptoms as independent outcomes. This examination used gender as a moderator to illuminate the intersections of gender, mental health, and discrimination. Data for the study derived from the 1995 Detroit Area Study (DAS). DAS used a multistage area probability sample involving face-to-face structured interviews in a cross-sectional design. The sample consisted of 570 adult participants, of whom 390 were Black men. The results indicated that although Black men reported more perceived everyday discrimination than did Black women, there were no differences noted in depressive symptoms across gender.

In the other study, Borrell, Kiefe, Williams, Diez-Roux, and Gordon-Larsen (2006) examined the association of self-reported physical and mental health status with perception of racial discrimination and also with skin color in African Americans. The data for their analysis were derived from coronary artery risk development in young adults study (CARDIA), a 15-year longitudinal prospective study that conducted follow-up examinations from 1985 to 2001. The sample included 1,722 African Americans, 700 of whom were men. Results indicated that self-perceived racial discrimination was more strongly associated with worse mental and physical health in women than in men. Additionally, African American men were more likely to be married, less educated, and more likely to be in the higher income categories than African American women, suggesting that being married and having a higher level of income may serve as protective factors for improved mental health among African American men.

The remaining 14 studies focused on various risk factors for MDD among African American men, including demographics, socioeconomic status, social issues, psychological status, and other medical health problems (see Table 2).

Fernandez, Mutran, Reitzes, and Sudha (1998) used a longitudinal data set derived from African American adults ages 58–64 years to examine whether depressive symptoms measured at baseline (1992) and 2 years later were differentially distributed by ethnicity and gender. The total sample included 749 Caucasian and African American adults, of whom 54 were African American men. The prospective investigation found that levels of depressive symptomatology did not vary significantly among White men, White women, and African American men. Work stressors influenced depressive symptoms, but the direct effects of work wore off over time for all groups, except for African American men, whose levels of depressive symptoms remained elevated by work stressors 2 years after their occurrence. Additionally, poor health elevated depressive symptoms among African American men. Whereas retirement decreased depressive symptoms in other groups, it increased depressive symptoms in African American men. Income was found to be a significant protective factor against depressive symptoms among African American men.

Similar to the findings linking work stress and depression, a series of studies showed that employment, earnings, job stability, and other work-related issues were connected to depression. For instance, Gary (1985) investigated how demographic factors, stressful life events, and sociocultural variables (i.e., racial discrimination) were correlated with depressive symptoms among African American men. A cross-sectional design was used with a heterogeneous sample of 142 Black men ages of 30 and older. Results indicated that Black men 30 years of age and under, earning <$8,000 a year, and living in households with five or more persons scored higher on the depression scale (CES-D) compared with their counterparts. Additionally, men who were unemployed and who had high or medium levels of conflict with their mate had the highest levels of depressive symptoms. In a similar study, Zimmerman, Christakis, and Vander Stoep (2004) examined the link between depression and job attributes for young adults. They used data from the National Longitudinal Survey of Youth and the U.S. Department of Labor O*Net Data set with a combined sample of 7,278, of whom 1,949 were African Americans (men = 982). Overall findings for men indicated that higher job status was associated with lower CES-D scores, suggesting that higher job status might be protective for depression. Furthermore, among Black men, unlike White men or Latinos, job security was associated with fewer depressive symptoms. In addition, every additional year of age was associated with a reduction in depression symptoms for Black men.

Hudson, Neighbors, Geronimus, and Jackson (2011) examined whether differences exist in the relationship between socioeconomic positioning and depression by gender. Socioeconomic positioning was defined as an individual’s socioeconomic measurement (e.g., low income, poverty level, unemployed, high income, or range of yearly income). Other indicators such as educational attainment are typically associated with socioeconomic positioning. Using a stratified and clustered sample design, data were drawn from NSAL. In-home, face-to-face interviews and computer-assisted personal interviewing were conducted among a sample of 3,570 African Americans, 1,181 of whom were African American men aged 18 years and older. Marital status was found to be a significant factor in predicting depression among men, but not women. Specifically, men in the divorced, separated, widowed, and never married categories reported significantly greater odds of major depression compared with married men. Results also indicated that, although unemployed African American men had significantly increased odds of depression, men in the higher income category ($80,000 and above) reported greater odds of depression than men in the lowest income category ($17,000 and below). Hudson et al. (2011) concluded that African American men earning higher incomes may be exposed to more racial discrimination in the work environment. Also, these men may experience more social conflicts because of spending less time with their social networks and may also face more demands to provide financial assistance to others in their social support network.

Several studies examined social issues associated with MDD among African American men. Mizell (1999) examined how factors of the adolescent home environment (parental composition and parental achievement), adolescent self-concept (adolescent self-esteem), adult achievement (adult earnings and mastery), and adult self-concept (adult self-esteem) influence depression in Black men. The data were drawn from the National Longitudinal Survey of Youth (NLSY). Two subsamples were used in this investigation, including 892 African American men and another subsample of 1,454 White men, spanning from 1979 to 1992. The sample consisted of men aged 14 years old at the time of the initial interview up to 31 years old at the final interview. Results indicated that belonging to a female-headed household did not produce significantly higher levels of depression in African American men compared with other family arrangements (e.g., two-parent homes, living with a grandparent). Evidence from this study noted an interesting pattern such that parental educational attainment was found to be a positive sequence of events for Black men. Specifically, Black men with increased parental educational attainment were seen to have greater adult achievement and self-concept and lower depression. Although parental educational attainment was found to be a significant protective factor for Black men, the degree of protection was less significant for Blacks compared with their White counterparts. Therefore, the overall findings across races indicated that for Black men, individual adult achievement and adult mastery may be more protective against depression than any other factors of the adolescent home environment (parental composition and adolescent or adult self-esteem).

Another study examined social network and depression among African Americans with a sample of 64 African American (33 men) patients voluntarily admitted to a hospital-based behavioral unit. In that study, all of the participants were depressed. Thirty-four percent (11) of the African American men reported a history of a suicide attempt, and 38% (12) reported no history of a suicide attempt. Findings indicated a poor or absent support network was a risk factor for suicide in this group (Palmer, 2001). In particular, depressed patients with no history of a suicide attempt reported higher perceived social support from family, suggesting that perceived social support may buffer against the risk of suicide (Palmer, 2001).

Lincoln et al. (2011) examined demographic factors associated with MDD among African American men aged 18 years or older. Data were drawn from NSAL, with a total sample of 6,082, of whom 1,271 were African American men. Results showed that demographic risk factors associated with having MDD in the past 12 months were age, poverty status, education, marital status, and geographical region. These findings appear to suggest that younger age groups (<55 years), income near poverty level, years of education (13–15 years), and marital status (separated, divorced, and widowed) were associated with MDD among African American men. Results also showed that marital status (separated, divorced, or widowed) as well as region (living in North Central region of the United States) were correlated with lifetime MDD.

In another study, Henderson et al. (2005) examined relationships between neighborhood socioeconomic and ethnic characteristics with depressive symptoms. Data were drawn from CARDIA, with a sample of 3,437, of whom 692 were African American men. Using the Center for Epidemiological Studies–Depression (CES-D) instrument, 24% of the African American men (n = 186) had mean scores suggesting clinical depression (CES-D >16), compared with 14% (n = 116) of White men. Neighborhood ethnic composition related to mental health, whereby rates of mental disorder decreased as the percentage of persons of the same ethnicity living in the community increased. However, Henderson et al. cautioned that their study results do not confirm a causal link between neighborhood ethnic density and depressive symptoms or that neighborhood ethnic density is a risk factor for depression.

One study was found suggesting alcohol abuse and dependence were associated with MDD among African American men. Kim, Han, Hill, Rose, and Roary (2003) examined relationships between depression, alcohol and illicit drug use, adherence behaviors, and blood pressure (BP) among Black men (N = 190). Results showed 27.4% of the sample exhibited high risk for depression (CES-D score >16). The most significant risk factor for depression among this group was low income (<$10,000 annual income). Men who reported incomes higher than $10,000 were 29% less likely to be depressed compared to men with an annual income of <$10,000. Also, depression was significantly associated with alcohol abuse and dependence, whereby Black men who were depressed were 5.2 times more likely to be abusing alcohol or dependent on alcohol (Kim et al., 2003).

Okwumabua, Baker, Wong, and Pilgram (1997) examined risk factors for depression among community-dwelling African American elders 60 years and older. The total sample consisted of 96 African Americans, of whom 48 were African American men. Twenty percent of the total sample screened positive (CES-D score >16) for depressive symptoms, and 8.9% of the men screened positive for depressive symptoms. Results showed depression to be comorbid with medical problems, including hypertension, arteriosclerosis, and circulatory problems, suggesting that medical illness was a significant predictor of depression among this group. Social network was also a significant predictor of depressive symptoms, whereby individuals who had poor or few relations with family and friends were more likely to report depressive symptoms.

Issues of Chronicity and Disability and Symptom Expression Over Time

On the basis of the studies in the present review, the prevalence of MDD among African American men ranges from 5% to 10%. Although the prevalence of MDD among African American men is lower compared with Caucasian men, African American men appear to experience higher rates of chronicity and disability. Given the disparity in chronicity and disability associated with MDD among African American men, it is clear that this group is burdened by MDD, which is negatively impacting their work life, relationships, and social life. Thus, it is important to know what factors may be causing these problems among this group. Could it be because of discrimination in the work place? Could it be because of conflicts in interpersonal relationships at home or with family? Could it be because of high rates of depression comorbid with substance use disorders or depression comorbid with medical conditions such as hypertension, diabetes, or arteriosclerosis?

From our review of the literature, it appears that older African American men have a higher prevalence of depression symptoms compared with elderly White men. Furthermore, the pattern of depression symptoms over time and the structures that protect or exacerbate risk for depression seem to vary among elderly men. For example, prior research indicated that, whereas occurrences of depression in retirement decreased in other groups, among Black elderly men, depression rates increased (Skarupski et al., 2005). Given that a large part of Black male identity is associated with the “provider role” (Diemer, 2002), perhaps losing the title of employed, even though still retired, is experienced differently for Black men in comparison with White men. Also, perhaps Black men are exposed to more difficult sociocultural realities when not working, which might increase their risk of depression in comparison with elderly White men. For example, reduction in income, limited access to resources to financially prepare for retirement, difficulty emotionally transitioning into the retirement role, and increased loss of loved ones. As of yet, these are only speculations; therefore, more research investigating prevalence and symptom expression patterns among elderly men is required to better understand these intricate patterns. With more research using a life course perspective examining depression patterns among Black men, these findings can shed light on risk factors that could inform development of culturally relevant prevention and intervention treatments.

Use of Risk Factor Knowledge

Results of the present review suggest there are a myriad of factors that increase African American men’s risk for MDD, including demographic, socioeconomic status, social issues, and other psychological and medical conditions. As documented by Gary (1985), one could speculate that the interaction of increased sociocultural factors (unemployment, limited or no health insurance, and poverty) could partly contribute in enhancing the chronicity patterns of depression among Black men in comparison with White men. However, some of these risk factors among African American men include social issues and psychological and medical conditions that might be modifiable. For example, Okwumabua et al.’s (1997) findings can be used to stress the importance of and inform prevention work for African American men with specific medical conditions. In doing so, effective, culturally appropriate treatment and after-care planning for Black men with medical problems, including hypertension, arteriosclerosis, and circulatory problems, can be devised to assess and monitor depression. The ultimate goal is to prevent or decrease the likelihood of untreated depression co-occurring with these and other medical conditions that are more common among African American men.

Additionally, there appear to be factors that are protective for this group regarding MDD, such as being married, level of income, higher job status and job security, adult achievement and sense of mastery (skills), and perceived social support. Interestingly, level of income appeared to be both a risk factor and a protective factor. As a risk factor, Hudson et al. (2011) suggested that higher incomes may place this group at risk of more racial discrimination in the work environment and also conflict with social networks such as demands to provide financial assistance. Better understanding of the risk factors and protective factors for MDD among African American men can inform development of critically needed culturally appropriate prevention and interventions programs for this group. For instance, prevention programs might include educating the African American community about mental illness and addressing misconceptions about mental illness, including stigma, risk factors, protective factors, and treatment options.

Attitudinal Beliefs and Treatment-Seeking Behavior

The literature focusing on use of mental health services among African American men is sparse. In this review, only five studies were identified that focused on treatment-seeking behaviors and use of mental health services. From these five studies, it appears that African American men’s use of mental health services is complex. For example, while African American men are more likely to use specialty mental health providers (psychiatrists and mental health counselors), they are less likely to see primary care physicians (Neighbors et al., 2007). Furthermore, less that 50% of African American men affected by mental illness actually seek treatment (Neighbors et al., 2007). Additionally, although African American men may not hold negative attitudes toward seeking mental health services, they do have attitudes and beliefs that seem to negatively affect treatment-seeking behaviors. It is possible that these attitudes and beliefs may be ingrained in Afrocentric cultural values, whereby concerns about stigma or negative perceptions about mental illness serve as a barrier to seeking mental health services. On the basis of findings by Sanders Thompson et al. (2004), it is also possible that African American men may not seek treatment because of the perception that seeking treatment is a sign of weakness and loss of strength or cultural pride.

Considering the negative impact of stigma on treatment seeking among African American men, there is a critical need for educational outreach programs to reduce stigma. For example, local educational outreach programs tailored specifically for African American men at the local or grassroots and national levels could include dissemination of educational materials in community settings such as community centers, churches, barber shops, and men’s athletic clubs.

Also, using a family-centered approach focusing on Black families could be useful, because marriage and perceived social supports are protective for this group.

On a national level, the National Institute of Mental Health’s (NIMH) campaign focusing on depression among men, “Real Men, Real Depression” (NIMH, 2012) could be beneficial; however, it needs to be tailored to African American men. Another possible national campaign might involve recruiting well-known African American athletes or actors to serve as spokespeople for mental health awareness campaigns. For example, in 2010, well-known African American basketball player Ron Artest publically thanked his psychiatrist during his speech after winning the NBA title (Black Sports Online, 2010). Artest’s public disclosure demonstrates some progress made in decreasing mental health stigma; however, more open dialogue about the normalcy of mental health issues and available treatment options is in dire need in the Black community. In sum, national and local outreach has the potential to reduce stigma associated with mental illness, increase treatment-seeking behaviors, improve mental health outcomes, and reduce mental health disparities among African American men.