Underestimating the Uniqueness: A Critique of Public Health’s Approach Towards Depression among African American Men - Christine Crawford
Introduction:
“No Black Man in America is ever mentally healthy”-Anonymous
(Black Mental Health Alliance, 2003)
The sentiment expressed in this statement unfortunately echoes the current state of mental health within the African American male community. Unfortunately 7% of African American men will develop depression during their lifetime which is most likely an underestimate of the actual amount due to the lack of screening and treatment services rendered by black men (Black Mental Health Alliance, 2003). According to the Surgeon General’s Report on Mental Health, rates of depression appear to be similar among blacks and whites, but there is apparent difference regarding the prevalence of different illnesses. The rates of suicide have generally been higher among whites but from 1980 to 1995 the rates of suicide among male black 10 to 14 year olds has increased by an astounding 233% (SAMSHA, 1999). The data that has been reported on depression is not reflective of the actual rates among black men since data collection is not successfully capturing this at risk population. It is certain that reported rates among black men would be increased if they were being properly diagnosed and treated for depression.
In this paper, I will argue that within public health professionals’ approach towards ameliorating depression among black men, they have not addressed the uniqueness of African American male socio-cultural factors, the residual effects of racism, and the adverse effects of integrating care to increase mental health services which all have contributed to untreated and misdiagnosed depression within this population.
Addressing the Uniqueness of African American Male Socio-cultural Factors:
“When we don’t feel we can provide for our families or protect our children, we feel worthless, depressed…this society only values what you do and not who you are”
–Anonymous (Black Mental Health Alliance, 2003).
The social and cultural context in which black men live has not been adequately addressed by mental health providers within their approach towards treating black men with depression.Issues concerning poverty, their sense of identity, and family structure all contribute towards the uniqueness of black men socio-cultural factors.
Contributing to social-cultural differences among black and white males is the high poverty rate among African American families. According to the U.S. Census Bureau, approximately 22.1% of African Americans were living in poverty in the year 2000 which is almost double the national poverty rate (U.S. Census Bureau, 2000). Although 12% of the nation’s people are homeless, African Americans make up about 40% of the homeless population in which males are dominant (SAMSHA, 1999). Additionally, research from the CARDIA study has proven that low income and unemployment are associated with depressive symptoms (Whooley, 2002).
Socioeconomic status of African Americans exacerbates the risk factors that would contribute to a greater prevalence of depression within this population. The financial strife which a large number of black men have to face has a considerable impact on qualities that black men feel are important aspects of their sense of identity. Research suggests that poverty contributes to a decrease sense of control in addition to a feeling of incompetence since they are struggling to uphold the male responsibility of financially supporting their family (Mizell, 1999). Since black men have greater difficulty of earning a living and maintaining a steady job, they are more likely to feel as if they are deviating from the social norm within the United States that work is a central component to the lives and identities of men. The impact of being perceived as less of a man due a poor financial situation contributes low self-esteem and consequently, depression (Mizell 1999).
Unlike the ability of being financially stable, the family dynamic and home environment in which black males are exposed are socio-cultural factors that they ultimately have no control over. The shear fact that 40% of African-American households are headed by a single mother illustrates the difference between black and white socio-cultural factors which contribute to depression. The absence of a male figure in these African American households has an adverse effect on black males since they are unable to establish a strong sense of positive ethnic and male identity, trust and self-esteem (Choi, 2002). Unfortunately for a large number of black males who are raised in these matriarchal households, the mothers are less likely to be highly educated compared to that of single white mothers (Choi, 2002). Growing up in a household in which there is not a strong educational presence contributes towards poor interpersonal connections since mothers have less time to spend with their children due to the fact that they are busy earning a living from low paying jobs (Choi, 2002).
The unique socio-cultural factors of black males explicitly set them apart from their white male counterparts. Although public health does acknowledge the fact that life stressors can contribute towards the manifestation of depression, there needs to be more of an awareness of black men’s unique stresses. The high levels of substance-abuse, violence, and alcoholism are mechanisms that are used by black men in order to assuage their depression (Rich, 2000).
Results of Not Addressing Residual Effects of Racism:
“We have a problem asking for help-especially from folks who we think are the reasons for our mental illness” (Black Mental Health Alliance, 2003).
Secondly, public health professionals and mental health care providers need to acknowledge the existing effects of institutionalized discrimination and internalized racism. Although public health professionals have made strides towards educating health care providers on cultural competency through highlighting various beliefs, histories, traditions, and value systems, the historical backdrop of racism and prejudice against blacks is still present in this country. According to the Surgeon General the majority of mental health providers do not belong to ethnic populations, which validates the push towards cultural competency among these providers (SAMSHA, 1999).
The sense of inferiority and inadequacy perceived by black males is the result of internalized racism. Mainstream values regarding perceptions of African American males have socialized members of this country contributing to the development of unconscious acceptance of racist views and practices (Kendall, 1996). Since the health care provider is naturally in a position of higher authority, this power stance will add to the feeling of inferiority, low self-esteem, and inadequacy that is experience that black men who are depressed. It is essential to dismantle the rift between patient and provider in order to effectively convey a sense of trust in the treatment in which they are providing. According to Judy Kendall, RN “it is reasonable to assume that when a member of a dominant or valued group provides treatment to a member of a dominated or devalued group, the same social tensions, fears, and resentments attached historically to the situation will affect the treatment process” (Kendall, 1996).
A history exists concerning mistrust of black men and the medical system. According to Kardiner and Ovesey, the only way to improve the self-esteem, value and mental well being of black men is by eliminating racism since the experience of living in a racist society has deemed depression treatment less effective (Kendall, 1996). Due to the experience that African American men have had, they are less likely to express their feelings and be open with their health care provider.
Flaws of Integrating Care to Treat Depression:
“After they told me, in their way, that I had a mental disorder, I never went back. They didn’t care and neither did I” –Anonymous (Black Mental Health Alliance, 2003).
Kyle Grazier, a public health professor focusing on depression and primary care at the University of Michigan, claims that integrating care is one way of public health can address depression and suggests having primary care physicians work together with mental health specialists in order support the growing need of mental health services (Stainton, 2005). Through this integrated method, primary care physicians will be given the tools and resources necessary in order to identify and treat depression among people from various backgrounds. Although this integrated approach does seem beneficial since half of people who are treated for their depression receive their treatment from their primary care provider, ultimately these patients are not receiving care from an expert within the field of mental health, specifically depression (Rabinowitz, 1998).
Inadequately trained primary care providers contribute towards diagnostic bias.
Black males are more likely to be mistakenly diagnosed as schizophrenic than whites due to the socio-cultural factors, which influence the presentation of depressive symptoms among black men (Baker, 2001). Unfortunately the percentage of misdiagnoses jumps to 90% for African Americans with depression, which far exceeds that of whites (Berg 2005). Since the socio-cultural context has the tendency of not being comprehensively assessed by the primary care physicians serving as mental health providers, black males’ hostility, increased negativism, irritability, and internalized anger due to their potential frustrations regarding their neighborhood, work, or family problems, are less likely to be viewed as depressive symptoms resulting in less treatment and possible misdiagnosis of schizophrenia (Baker, 2001).
Unfortunately within this approach, there is the possibility of having primary care physicians treating depression among black men who are not fully invested in mental health issues. This sense of detachment contributes to the likelihood that the specific qualities and nuances of depression among black men will be overlooked and inadequately addressed. Since these primary care providers are simply given the basics behind intervention, treatment and symptoms of depression, they do not have enough knowledge for attending to black male depression. Within the context of primary care providers treating black men with depression, the social, cultural, and economic framework of the black male experience are not laid down as the foundation from which treatment and prevention should occur.
Research also suggest that there is a tendency for many health care providers to overlook the importance of cultural differences such as the fact black males do not like to speak about their personal life, specifically to clinicians who they have a lack of trust, resulting in the clinician misinterpreting their uncommunicativeness as a possible symptom for schizophrenia (Berg, 2001). Within the area of ethnic differences pertaining to depression has found three alternative presentations of depressive symptoms among African Americans: the stoic believer, the angry, evil one with a personality change, and the John Henry doer (Baker, 2001). The stoic believer presentation applies to those who do not report their depressive symptoms since religion plays a major role in modifying their depressive complaints. The angry, evil one with a personality change presentation largely applies to African American men experiencing the stressors of socio-cultural factors since patients tend to present as being angry, irritable, and abrupt in their responses. Due to this presentation of depressive symptoms, depressed black males often engage in self-destructive activities in particularly homicide (Baker, 2001). Lastly, the John Henry presentation is the result of the pressure that black males experience within this country overwhelmed all of the challenges and tasks that he must face in order to satisfy expectations placed upon themselves and as well as their families.
Possible Intervention
“We need a good list of Black mental health professionals who understand the plight of Black men in this country and who will not prejudge us, but who will listen to our pain and feelings of frustration” -Anonymous (Black Mental Health Alliance, 2003).
Unfortunately, public health professionals are not providing sufficient education to health care providers regarding the subtly of the unconscious underlying presence of prejudice and racism when they first encounter a black male patient which has adverse effects on the treatment and diagnosis of their depression. In order to ameliorate this problem, public health professionals need to educate these health care providers about the alternative presentation of depression among black men, which is a strategy that has yet to be widely implemented and acknowledged.
In order to successfully change black men’s perception on seeking depression treatment, public health professionals need to use effective persuasive communication while utilizing an empirical–rational strategy. By using this approach, African American men and mental health providers will be presented with educational materials that would be used as a means for assisting in making rational decisions focusing on changing perceptions of depression among black men. Primary care physicians providing mental health services should be educated on recognizing how socio-cultural factors and racism contributes to different presentations of depressive symptoms within the black male population.
One approach towards establishing an effective and persuasive means of getting more black men to seek and receive treatment is to have a stronger focus on group therapy headed by a black male preferably from the same community. As previously mentioned, there have been attempts made by public health professionals educate health providers about the history of different cultures, but they have failed to address how the black male patient perceives his physician and which steps need to be taking in order to eliminate a sense of inferiority. Although the number of minority mental health providers is rather scarce, having someone from a minority background providing the treatment will eliminate the inferiority complex and lack of self-esteem that is often experienced when these men receive treatment from a white primary care physician.
Taking an approach with this perspective, public health can shape its educational tactic to emphasize the importance of enhancing self-concept as a means to be a stronger black man within the community in order to help others rise out of the oppression that racism and inequality have placed among African Americans for many years. If public health is trying to work with a population that possesses a lack of self-efficacy and a negative perception of their ethnicity, then they need to incorporate an element within their public health efforts that stresses the importance of boosting self-worth, self-efficacy, ethnic identity while seeking depression treatment through a rational-empirical approach.
Conclusion
Although public health is cognizance of the effects of depression among black men, using the ideas that were mentioned will exponentially increase the number of black men seeking adequate treatment. As previously stated, public health professionals have not focused their approaches towards black male depression by addressing the uniqueness of African American male socio-cultural factors, the residual effects of racism, and effects of integration of care within mental health services contributing to inadequate diagnosis and treatment of depression among black men. Despite these flaws, there is still great hope that public health increase research within this field to develop innovative approaches towards addressing this issue.
Works Cited
Baker, F.M. (2001). Diagnosing Depression in African Americans [Electronic version]. Community Mental Health Journal, 37, 31-38
Berg, S. (2005). The color of bp. BP Magazine. Retrieved November 24, 2006, from http://www.bphope.com/
Choi, H. (2002). Understanding adolescent depression in ethnocultural context [Electronic version]. Advances in Nursing Science, 25, 71-85.
Dunlop, D. (2003). Racial/ethnic differences in rates of depression among preretirement adults. American Journal of Public Health, 93, 1945-1952.
Kendall, J. (1996). Creating a culturally responsive psychotherapeutic environment for African American youths: a critical analysis. Advances in Nursing Science, 18, 11-28. Retrieved December 2, 2006, from Ovid.
Mizell, C. (1999). Life course influences on African American men’s depression: adolescent parental composition, self-concept, and adult earnings. Journal of Black Studies, 29, 467-490. Retrieved November 12, 2006, from JSTOR.
Rabinowitz, J. (1998). Which primary care physicians treat depression? [Electronic Version] Psychiatric Services
Rich, J. (2000). The health of African American men. [Electronic Version] The Annals of the Ameriacn Academy, 569, 149-159.
Stainton, L. (2005). Depression. Retrieved December 2, 2006, from http://ww.sph.umich.edu/news_events/findings/fall05/features/one.htm
Thambirajah, M. (2005). Psychological Basis of Psychiatry. New York: Elsevier Limited.
SAMSHA. Surgeon General’s Mental Health Report. Retrieved November 29, 2006, from http://mentalhealth.samhsa.gov/cre/fact1.asp
Whooley, M., Kiefe, C., Chesney, M., Markovitz, J., Matthews, K., Hulley, S. (2002). Depressive symptoms, unemployment, and loss of income: the CARDIA study. Archive of Internal Medicine, 162, 2614-2620.
“No Black Man in America is ever mentally healthy”-Anonymous
(Black Mental Health Alliance, 2003)
The sentiment expressed in this statement unfortunately echoes the current state of mental health within the African American male community. Unfortunately 7% of African American men will develop depression during their lifetime which is most likely an underestimate of the actual amount due to the lack of screening and treatment services rendered by black men (Black Mental Health Alliance, 2003). According to the Surgeon General’s Report on Mental Health, rates of depression appear to be similar among blacks and whites, but there is apparent difference regarding the prevalence of different illnesses. The rates of suicide have generally been higher among whites but from 1980 to 1995 the rates of suicide among male black 10 to 14 year olds has increased by an astounding 233% (SAMSHA, 1999). The data that has been reported on depression is not reflective of the actual rates among black men since data collection is not successfully capturing this at risk population. It is certain that reported rates among black men would be increased if they were being properly diagnosed and treated for depression.
In this paper, I will argue that within public health professionals’ approach towards ameliorating depression among black men, they have not addressed the uniqueness of African American male socio-cultural factors, the residual effects of racism, and the adverse effects of integrating care to increase mental health services which all have contributed to untreated and misdiagnosed depression within this population.
Addressing the Uniqueness of African American Male Socio-cultural Factors:
“When we don’t feel we can provide for our families or protect our children, we feel worthless, depressed…this society only values what you do and not who you are”
–Anonymous (Black Mental Health Alliance, 2003).
The social and cultural context in which black men live has not been adequately addressed by mental health providers within their approach towards treating black men with depression.Issues concerning poverty, their sense of identity, and family structure all contribute towards the uniqueness of black men socio-cultural factors.
Contributing to social-cultural differences among black and white males is the high poverty rate among African American families. According to the U.S. Census Bureau, approximately 22.1% of African Americans were living in poverty in the year 2000 which is almost double the national poverty rate (U.S. Census Bureau, 2000). Although 12% of the nation’s people are homeless, African Americans make up about 40% of the homeless population in which males are dominant (SAMSHA, 1999). Additionally, research from the CARDIA study has proven that low income and unemployment are associated with depressive symptoms (Whooley, 2002).
Socioeconomic status of African Americans exacerbates the risk factors that would contribute to a greater prevalence of depression within this population. The financial strife which a large number of black men have to face has a considerable impact on qualities that black men feel are important aspects of their sense of identity. Research suggests that poverty contributes to a decrease sense of control in addition to a feeling of incompetence since they are struggling to uphold the male responsibility of financially supporting their family (Mizell, 1999). Since black men have greater difficulty of earning a living and maintaining a steady job, they are more likely to feel as if they are deviating from the social norm within the United States that work is a central component to the lives and identities of men. The impact of being perceived as less of a man due a poor financial situation contributes low self-esteem and consequently, depression (Mizell 1999).
Unlike the ability of being financially stable, the family dynamic and home environment in which black males are exposed are socio-cultural factors that they ultimately have no control over. The shear fact that 40% of African-American households are headed by a single mother illustrates the difference between black and white socio-cultural factors which contribute to depression. The absence of a male figure in these African American households has an adverse effect on black males since they are unable to establish a strong sense of positive ethnic and male identity, trust and self-esteem (Choi, 2002). Unfortunately for a large number of black males who are raised in these matriarchal households, the mothers are less likely to be highly educated compared to that of single white mothers (Choi, 2002). Growing up in a household in which there is not a strong educational presence contributes towards poor interpersonal connections since mothers have less time to spend with their children due to the fact that they are busy earning a living from low paying jobs (Choi, 2002).
The unique socio-cultural factors of black males explicitly set them apart from their white male counterparts. Although public health does acknowledge the fact that life stressors can contribute towards the manifestation of depression, there needs to be more of an awareness of black men’s unique stresses. The high levels of substance-abuse, violence, and alcoholism are mechanisms that are used by black men in order to assuage their depression (Rich, 2000).
Results of Not Addressing Residual Effects of Racism:
“We have a problem asking for help-especially from folks who we think are the reasons for our mental illness” (Black Mental Health Alliance, 2003).
Secondly, public health professionals and mental health care providers need to acknowledge the existing effects of institutionalized discrimination and internalized racism. Although public health professionals have made strides towards educating health care providers on cultural competency through highlighting various beliefs, histories, traditions, and value systems, the historical backdrop of racism and prejudice against blacks is still present in this country. According to the Surgeon General the majority of mental health providers do not belong to ethnic populations, which validates the push towards cultural competency among these providers (SAMSHA, 1999).
The sense of inferiority and inadequacy perceived by black males is the result of internalized racism. Mainstream values regarding perceptions of African American males have socialized members of this country contributing to the development of unconscious acceptance of racist views and practices (Kendall, 1996). Since the health care provider is naturally in a position of higher authority, this power stance will add to the feeling of inferiority, low self-esteem, and inadequacy that is experience that black men who are depressed. It is essential to dismantle the rift between patient and provider in order to effectively convey a sense of trust in the treatment in which they are providing. According to Judy Kendall, RN “it is reasonable to assume that when a member of a dominant or valued group provides treatment to a member of a dominated or devalued group, the same social tensions, fears, and resentments attached historically to the situation will affect the treatment process” (Kendall, 1996).
A history exists concerning mistrust of black men and the medical system. According to Kardiner and Ovesey, the only way to improve the self-esteem, value and mental well being of black men is by eliminating racism since the experience of living in a racist society has deemed depression treatment less effective (Kendall, 1996). Due to the experience that African American men have had, they are less likely to express their feelings and be open with their health care provider.
Flaws of Integrating Care to Treat Depression:
“After they told me, in their way, that I had a mental disorder, I never went back. They didn’t care and neither did I” –Anonymous (Black Mental Health Alliance, 2003).
Kyle Grazier, a public health professor focusing on depression and primary care at the University of Michigan, claims that integrating care is one way of public health can address depression and suggests having primary care physicians work together with mental health specialists in order support the growing need of mental health services (Stainton, 2005). Through this integrated method, primary care physicians will be given the tools and resources necessary in order to identify and treat depression among people from various backgrounds. Although this integrated approach does seem beneficial since half of people who are treated for their depression receive their treatment from their primary care provider, ultimately these patients are not receiving care from an expert within the field of mental health, specifically depression (Rabinowitz, 1998).
Inadequately trained primary care providers contribute towards diagnostic bias.
Black males are more likely to be mistakenly diagnosed as schizophrenic than whites due to the socio-cultural factors, which influence the presentation of depressive symptoms among black men (Baker, 2001). Unfortunately the percentage of misdiagnoses jumps to 90% for African Americans with depression, which far exceeds that of whites (Berg 2005). Since the socio-cultural context has the tendency of not being comprehensively assessed by the primary care physicians serving as mental health providers, black males’ hostility, increased negativism, irritability, and internalized anger due to their potential frustrations regarding their neighborhood, work, or family problems, are less likely to be viewed as depressive symptoms resulting in less treatment and possible misdiagnosis of schizophrenia (Baker, 2001).
Unfortunately within this approach, there is the possibility of having primary care physicians treating depression among black men who are not fully invested in mental health issues. This sense of detachment contributes to the likelihood that the specific qualities and nuances of depression among black men will be overlooked and inadequately addressed. Since these primary care providers are simply given the basics behind intervention, treatment and symptoms of depression, they do not have enough knowledge for attending to black male depression. Within the context of primary care providers treating black men with depression, the social, cultural, and economic framework of the black male experience are not laid down as the foundation from which treatment and prevention should occur.
Research also suggest that there is a tendency for many health care providers to overlook the importance of cultural differences such as the fact black males do not like to speak about their personal life, specifically to clinicians who they have a lack of trust, resulting in the clinician misinterpreting their uncommunicativeness as a possible symptom for schizophrenia (Berg, 2001). Within the area of ethnic differences pertaining to depression has found three alternative presentations of depressive symptoms among African Americans: the stoic believer, the angry, evil one with a personality change, and the John Henry doer (Baker, 2001). The stoic believer presentation applies to those who do not report their depressive symptoms since religion plays a major role in modifying their depressive complaints. The angry, evil one with a personality change presentation largely applies to African American men experiencing the stressors of socio-cultural factors since patients tend to present as being angry, irritable, and abrupt in their responses. Due to this presentation of depressive symptoms, depressed black males often engage in self-destructive activities in particularly homicide (Baker, 2001). Lastly, the John Henry presentation is the result of the pressure that black males experience within this country overwhelmed all of the challenges and tasks that he must face in order to satisfy expectations placed upon themselves and as well as their families.
Possible Intervention
“We need a good list of Black mental health professionals who understand the plight of Black men in this country and who will not prejudge us, but who will listen to our pain and feelings of frustration” -Anonymous (Black Mental Health Alliance, 2003).
Unfortunately, public health professionals are not providing sufficient education to health care providers regarding the subtly of the unconscious underlying presence of prejudice and racism when they first encounter a black male patient which has adverse effects on the treatment and diagnosis of their depression. In order to ameliorate this problem, public health professionals need to educate these health care providers about the alternative presentation of depression among black men, which is a strategy that has yet to be widely implemented and acknowledged.
In order to successfully change black men’s perception on seeking depression treatment, public health professionals need to use effective persuasive communication while utilizing an empirical–rational strategy. By using this approach, African American men and mental health providers will be presented with educational materials that would be used as a means for assisting in making rational decisions focusing on changing perceptions of depression among black men. Primary care physicians providing mental health services should be educated on recognizing how socio-cultural factors and racism contributes to different presentations of depressive symptoms within the black male population.
One approach towards establishing an effective and persuasive means of getting more black men to seek and receive treatment is to have a stronger focus on group therapy headed by a black male preferably from the same community. As previously mentioned, there have been attempts made by public health professionals educate health providers about the history of different cultures, but they have failed to address how the black male patient perceives his physician and which steps need to be taking in order to eliminate a sense of inferiority. Although the number of minority mental health providers is rather scarce, having someone from a minority background providing the treatment will eliminate the inferiority complex and lack of self-esteem that is often experienced when these men receive treatment from a white primary care physician.
Taking an approach with this perspective, public health can shape its educational tactic to emphasize the importance of enhancing self-concept as a means to be a stronger black man within the community in order to help others rise out of the oppression that racism and inequality have placed among African Americans for many years. If public health is trying to work with a population that possesses a lack of self-efficacy and a negative perception of their ethnicity, then they need to incorporate an element within their public health efforts that stresses the importance of boosting self-worth, self-efficacy, ethnic identity while seeking depression treatment through a rational-empirical approach.
Conclusion
Although public health is cognizance of the effects of depression among black men, using the ideas that were mentioned will exponentially increase the number of black men seeking adequate treatment. As previously stated, public health professionals have not focused their approaches towards black male depression by addressing the uniqueness of African American male socio-cultural factors, the residual effects of racism, and effects of integration of care within mental health services contributing to inadequate diagnosis and treatment of depression among black men. Despite these flaws, there is still great hope that public health increase research within this field to develop innovative approaches towards addressing this issue.
Works Cited
Baker, F.M. (2001). Diagnosing Depression in African Americans [Electronic version]. Community Mental Health Journal, 37, 31-38
Berg, S. (2005). The color of bp. BP Magazine. Retrieved November 24, 2006, from http://www.bphope.com/
Choi, H. (2002). Understanding adolescent depression in ethnocultural context [Electronic version]. Advances in Nursing Science, 25, 71-85.
Dunlop, D. (2003). Racial/ethnic differences in rates of depression among preretirement adults. American Journal of Public Health, 93, 1945-1952.
Kendall, J. (1996). Creating a culturally responsive psychotherapeutic environment for African American youths: a critical analysis. Advances in Nursing Science, 18, 11-28. Retrieved December 2, 2006, from Ovid.
Mizell, C. (1999). Life course influences on African American men’s depression: adolescent parental composition, self-concept, and adult earnings. Journal of Black Studies, 29, 467-490. Retrieved November 12, 2006, from JSTOR.
Rabinowitz, J. (1998). Which primary care physicians treat depression? [Electronic Version] Psychiatric Services
Rich, J. (2000). The health of African American men. [Electronic Version] The Annals of the Ameriacn Academy, 569, 149-159.
Stainton, L. (2005). Depression. Retrieved December 2, 2006, from http://ww.sph.umich.edu/news_events/findings/fall05/features/one.htm
Thambirajah, M. (2005). Psychological Basis of Psychiatry. New York: Elsevier Limited.
SAMSHA. Surgeon General’s Mental Health Report. Retrieved November 29, 2006, from http://mentalhealth.samhsa.gov/cre/fact1.asp
Whooley, M., Kiefe, C., Chesney, M., Markovitz, J., Matthews, K., Hulley, S. (2002). Depressive symptoms, unemployment, and loss of income: the CARDIA study. Archive of Internal Medicine, 162, 2614-2620.
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