Lifetime and Twelve-Month Prevalence, Persistence, and Unmet Treatment Needs of Mood, Anxiety, and Substance Use Disorders in African American and U.S. versus Foreign-Born Caribbean Women


International  Journal  of

Environmental Research

and Public Health

Article

Lifetime and Twelve-Month Prevalence, Persistence,
and Unmet Treatment Needs of Mood, Anxiety,
and Substance Use Disorders in African American
and U.S. versus Foreign-Born Caribbean Women

Audrey L. Jones 1,2,*, Susan D. Cochran 3,4, Jane Rafferty 5, Robert Joseph Taylor 5,6

and Vickie M. Mays 4,7

1 Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), Veteran Affairs Salt Lake City
Health Care System, Salt Lake City, UT 84148, USA

2 Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT 84132, USA
3 Departments of Epidemiology and Statistics, Fielding School of Public Health, University of California,

Los Angeles, CA 90095, USA; cochran@ucla.edu
4 UCLA Center for Bridging Research Innovation, Training and Education for Minority Health Disparities

Solutions (BRITE), Los Angeles, CA 90095, USA; mays@ucla.edu
5 Program for Research on Black Americans, Institute of Social Research, Ann Arbor, MI 48106, USA;

jraffrty@umich.edu (J.R.); rjtaylor@umich.edu (R.J.T.)
6 School of Social Work, University of Michigan, Ann Arbor, MI 48109, USA
7 Departments of Psychology and Health Policy and Management, Fielding School of Public Health,

University of California, Los Angeles, CA 90095, USA
* Correspondence: Audrey.Jones3@va.gov

Received: 31 August 2020; Accepted: 17 September 2020; Published: 25 September 2020
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Abstract: There is growing diversity within the Black population in the U.S., but limited understanding
of ethnic and nativity differences in the mental health treatment needs of Black women. This study
examined differences in the prevalence of psychiatric disorders, their persistence, and unmet treatment
needs among Black women in the U.S. Data were from the National Survey of American Life, a nationally
representative survey that assessed lifetime and twelve-month mood, anxiety, and substance use disorders
according to the Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV) criteria,
and mental health service use among those meeting disorder criteria. One in three African American
women met criteria for a lifetime disorder, compared to one in three Caribbean women born within the
U.S. and one in five Caribbean women born outside the U.S. About half of African American women
with a lifetime disorder had a persistent psychiatric disorder, compared to two in five Caribbean women
born within the U.S. and two in three Caribbean women born outside the U.S. African Americans had
more persisting dysthymia and panic disorder and less persisting social phobia compared to foreign-born
Caribbean women. Of the three groups, Caribbean women born within the U.S. were most likely to seek
mental health treatment during their lifetime. These results demonstrate, despite a lower prevalence of
psychiatric disorders in Black women, that there is a great likelihood their disorders will be marked by
persistence and underscores the need for culturally specific treatment approaches. As Black immigrants
in the United States are increasing in number, adequate mental health services are needed.

Keywords: mental health; DSM-IV; race/ethnicity; nativity; psychopathology; Black lives matter

1. Introduction

Psychiatric epidemiologic surveys have estimated patterns of mental health and substance use
disorders for adults in the United States (U.S.), including African Americans, since the 1980s, but the

Int. J. Environ. Res. Public Health 2020, 17, 7007; doi:10.3390/ijerph17197007 www.mdpi.com/journal/ijerph

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Int. J. Environ. Res. Public Health 2020, 17, 7007 2 of 22

scope of mental health treatment needs of Black women varying in ethnicity and nativity is not fully
known [1]. The first studies to characterize the prevalence of mental health disorders among women
using population-based designs found Black women to have a similar or lower prevalence of disorders
compared to White women, with some exceptions based on the type of disorder and subpopulation
characteristics [2,3]. In the Epidemiologic Catchment Area (ECA) study in the 1980s, it was observed that
African Americans had an equal or lower likelihood of major depressive disorder (MDD) compared to
Non-Hispanic Whites. However, young African American women (age 18–24) in the ECA had higher
rates of MDD than did young Non-Hispanic White women [4]. In the National Comorbidity Survey (NCS)
in the 1990s, Black women had lower rates of MDD compared to White or Hispanic women, except for
a finding of elevated prevalence of MDD for Black women ages 35–44 [5]. In the ECA, Black women
were found to have a higher prevalence of drug abuse compared to White women, but there were no
Black–White differences in alcohol abuse [6]. While later studies from the National Epidemiologic Survey
of Alcohol and Related Conditions (NESARC), conducted in the early 2000s, found the prevalence of
substance use disorders among Black women to also be similar to or lower than the prevalence observed in
White women [7,8]. Other mood disorders (i.e., dysthymia, bipolar I/II) and common anxiety disorders
were not reported for Black women in the ECA, NCS, or NESARC.

A limitation of the population-based studies of Black women’s mental health conducted prior to 2000
is that these studies primarily focused on Black vs. White differences, as samples were not drawn with
attention to the variation within the Black population. Approximately twenty percent of the recent growth
of the Black population in the U.S. is due to immigration [9], and Caribbean immigrants make up a large
portion of the foreign-born Black population [10]. By 2000, the Caribbean Black population was larger and
growing faster than other racial or ethnic populations, such as Cubans or Koreans [10]. In 2016, almost half
of the 1.6 million Black immigrants in the U.S. came from the Caribbean countries of Jamaica and Haiti [11].
Caribbean Blacks and African-Americans have different cultural and historical colonial experiences that
may portend different patterns as protective or predictive of mental health disorders [12].

Consistent with the healthy immigrant hypothesis, prior studies comparing the prevalence of mental
health and substance use disorders based on nativity found foreign-born adults to have a lower prevalence
of disorders than their U.S.-born counterparts [13–16], although many of these studies were conducted in
Latino and Asian populations. Studies in the United Kingdom have generally found that the rate of mental
disorders was comparable for Caribbean Black women and European White women [17,18]. It is not clear
if results from the United Kingdom would generalize to the U.S. The National Survey of American Life
(NSAL; 2001–2003), the first representative population-based psychiatric epidemiologic survey to sample
African American and Caribbean populations in the U.S. [19], can help to answer this question for mood,
anxiety, and substance use disorders (see Table 1).

For mood disorders, in addition to confirming the sometimes lower prevalence of MDD for African
American versus White women [20–23], studies from the NSAL found no differences in the prevalence
of MDD or dysthymia for African American and Caribbean Black women [12,22]; African American
mothers had elevated rates of bipolar disorder [23]. When nativity was considered, U.S.-born Caribbean
women were found to have higher rates of any mood disorder compared to foreign-born Caribbean
women [24]. For anxiety disorders, the NSAL revealed that African American women have a higher
lifetime prevalence of post-traumatic stress disorder (PTSD) compared to Caribbean Black women [12];
there were no ethnic differences in the prevalence of other measured anxiety disorders, such as
generalized anxiety disorder or panic disorder [12,22,25]. Foreign-born Caribbean women also had
lower rates of any anxiety disorder compared U.S.-born Caribbean Black women. For substance use
disorders, African American women were found to have a higher prevalence of alcohol abuse compared
to Caribbean Black women [12]. Moreover, when nativity was considered, foreign-born Caribbean
women were found to have an even lower prevalence of any substance use disorder compared to
U.S.-born Caribbean or African American women [12,24,26]. However, research into the prevalence of
specific mental health or substance use disorders in foreign-born Caribbean women, such as MDD or
panic disorder, remains sparse [27].



Int. J. Environ. Res. Public Health 2020, 17, 7007 3 of 22

Table 1. Findings from previous population-based studies of specific DSM-IV mood, anxiety, and substance use psychiatric disorders in African American and
Caribbean women in the U.S.

Psychiatric Disorder
Population-Based

Study
Diagnostic

Criteria
Prevalence Observation
Period [Reference no.] a

Rates of
Disorder by
Ethnicity?

Rates of
Disorder by

Nativity?

Groups of Women
Compared

Main Finding

Mood Disorders

Major Depressive Disorder ECA DSM-III 6 mo. [28] No No Black < White Rates of MDD among Black women are less than or
equal to that of White women.ECA DSM-III 6 mo. [4], 12 mo., [29] No No Black ≤ White

Lifetime [4] No No Black ≤ White (same as above)

NCS DSM-III R 30 day [5] No No Black ≤ White (same as above)

NSAL DSM-IV 12 mo., Lifetime [22,23] Yes No NHW > CB = AA (same as above)

NSAL DSM-IV 12 mo. [20], Lifetime [20,21] No No AA ≤ White (same as above)

NSAL DSM-IV Lifetime [12] Yes No AA = CB No ethnic differences observed among women.

NSAL DSM-IV 12 mo., Lifetime [30,31] No No AA only
Sociodemographic correlates of MDD differ for AA

men compared to AA women.

Dysthymia NSAL DSM-IV 12 mo. Lifetime [23] Yes No AA = CB = NHW No ethnic differences observed among women.

NSAL DSM-IV Lifetime [12] Yes No AA = CB No ethnic differences observed among women.

Bipolar Disorder I, II NSAL DSM-IV 12 mo., Lifetime [23] Yes No AA ≥ CB = NHW
Rates of bipolar disorder are sometimes higher for AA

women.

NSAL DSM-IV Lifetime [12] Yes No AA = CB No ethnic differences observed among women.

Any Mood Disorder NSAL DSM-IV
12 mo. [24],

Lifetime [12,24,32]
Yes Yes

AA = CB;
U.S.-born CB >

Foreign-born CB

No ethnic differences observed among women.
Foreign-born status appears protective for women.

Anxiety Disorders

Agoraphobia NSAL DSM-IV 12 mo. [25], Lifetime [12] Yes No CB = AA = NHW No ethnic difference observed among women.

Post-traumatic Stress
Disorder

NESARC DSM-IV TR Lifetime [33] No No NHB = NHW No ethnic differences observed among women.

NSAL DSM-IV 12 mo. [25] Yes No CB = AA = NHW No ethnic differences observed among women.

NSAL DSM-IV Lifetime [12] Yes No AA > CB AA women have higher prevalence of PTSD.

Social Phobia NSAL DSM-IV 12 mo. [25] Yes No NHW > CB = AA White women have highest rates of social phobia

General Anxiety Disorder NSAL DSM-IV 12 mo. [25], Lifetime [12] Yes No NHW > CB = AA White women have the highest rates of GAD.

Panic Disorder NSAL DSM-IV 12 mo. [25], Lifetime [12] Yes No CB = AA = NHW No ethnic differences observed among women.

Any Anxiety Disorder NSAL DSM-IV
12 mo. [24],

Lifetime [12,24,32]
Yes Yes

AA > CB;
U.S.-born CB >

Foreign-born CB

AA women have higher rates of anxiety disorders
compared to CB women. Foreign-born status appears

protective for women.



Int. J. Environ. Res. Public Health 2020, 17, 7007 4 of 22

Table 1. Cont.

Psychiatric Disorder
Population-Based

Study
Diagnostic

Criteria
Prevalence Observation
Period [Reference no.] a

Rates of
Disorder by
Ethnicity?

Rates of
Disorder by

Nativity?

Groups of Women
Compared

Main Finding

Substance Use Disorders

Alcohol Abuse ECA b DSM-III 6 mo. [6,28] No No Black = White There are few racial differences in the prevalence of
alcohol disorders among Black and White women.

NESARC DSM-IV 12 mo. [7] No No Black < White

NSAL DSM-IV Lifetime [12] Yes No AA > CB AA women have higher rates of alcohol abuse

Alcohol Dependence NESARC DSM-IV 12 mo., Lifetime [7,8] No No Black = White No racial differences among women.

NSAL DSM-IV Lifetime [12] Yes No AA = CB No ethnic differences among women.

Drug Abuse ECA c DSM-III 6 mo. [28] No No Black > White
Rates of drug use are sometimes higher for black

women than for white women

NSAL DSM-IV Lifetime [12] Yes No AA = CB No ethnic differences among women.

Drug Dependence ECAc DSM-III 6 mo. [28] No No Black = White No racial differences among women.

NSAL DSM-IV Lifetime [12] Yes No AA = CB No ethnic differences among women.

Any Substance Use
Disorder

NSAL DSM-IV
12 mo. [24,26],

Lifetime [12,24,26,32]
Yes Yes

AA > CB;
U.S.-born CB >

Foreign-born CB

AA women have higher rates of substance disorders
compared to CB women. Foreign-born status appears

protective for women.

Any of the Above
Disorders

NSAL DSM-IV
12 mo. [24],

Lifetime [12,24]
Yes Yes

AA > CB;
U.S.-born CB >

Foreign-born CB

Rates of having at least one measured disorder are
higher for AA women compared to CB women.

Foreign-born status appears protective.

Abbreviations. ECA = Epidemiologic Catchment Area Study (1980–1983); NCS = National Comorbidity Survey (1990–1992); NCS-R = National Comorbidity Survey Replication (2001–2003);
NSAL = National Survey of American Life (2001–2003); NESARC = National Epidemiologic Study of Alcohol and Related Conditions, Wave I (2001–2002); AA = African American;
CB = Caribbean Black; NHW = Non-Hispanic White; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition a Number in bracket refers to bibliographic reference;
b Rates of alcohol or dependence; c Rates of drug abuse or dependence.



Int. J. Environ. Res. Public Health 2020, 17, 7007 5 of 22

While the NSAL and earlier psychiatric epidemiologic studies provide insight into the prevalence
of mental health and substance use disorders, prevalence alone does not capture the full story for Black
women. Indeed, prior studies of the general population found that disorder prevalence is often lower in
Black versus White populations, and when present these disorders are more severe, persisting in their
course, and more often untreated [22,34]. In one study of Black men’s mental health from the NSAL,
foreign-born Caribbean men were more likely than other Black men to have persisting anxiety disorders,
such as generalized anxiety disorder and social phobia [35]. Thus, the sometimes-observed lower
prevalence of disorders can mask the real burden of mental health disorders within the Black population.

To our knowledge, prior studies have not triangulated information on prevalence,
persistence, and service utilization for Black women differing in ethnicity and place of birth. In addition,
we rarely see mental health services attending to these differences as part of a goal to provide culturally
specific mental health interventions. Black women, compared to other racial or ethnic groups, are less likely
to be married and be head of their households [36]; this sets up a dynamic for children and other dependents
to be impacted by mothers whose mental health needs are not being addressed. Research into the mental
health of Black women is especially important at present when the Black Lives Matter movement has
called attention into the ways in which systemic racism weighs on Black women in the U.S., from increased
interactions with the justice system for themselves and others in their households [37] to disparities in
maternal mortality [38]. Understanding the history of the psychiatric disorder patterns experienced by
diverse groups of Black women could help with developing culturally tailored solutions to improve
women’s mental health currently and provide cause for acceleration in addressing inequities in the field of
mental health treatments going forward.

2. Study Aim

Drawing on data from the NSAL, the goal of this study is to determine the prevalence, persistence,
and unmet treatment needs of mood, anxiety, and substance use disorders among African American
and Caribbean women in the U.S. We further examine the profile of mental health and substance
use disorders for U.S.-born and foreign-born Caribbean women to better understand the diversity of
mental health issues in Black women in the U.S. Our goal is to provide insights into how the patterns
of various mental health and substance use disorders may change relative to nativity, the persistence
of the disorders, and the unmet treatment needs of Black subpopulations of diverse women.

3. Methods

3.1. Procedures

This cross-sectional study uses data from the NSAL (2001–2003), an epidemiologic survey of
psychiatric disorders aligned with the Diagnostic and Statistical Manual of Mental Disorders 4th Edition
[DSM-IV] criteria, and mental health service utilization among Black Americans [39]. As described
elsewhere, the NSAL is the largest survey of psychiatric disorders of Black Americans to date, as well as
the first nationally representative survey of Black Caribbeans [40]. The four-stage probability sampling
design focused on U.S. households where at least one Black adult (age 18 or older) resided in the
contiguous U.S. To ensure adequate representation of Black adults of Caribbean descent, the NSAL
oversampled geographic areas with a high density (at least 10%) of Black Americans who were also of
Caribbean heritage.

Trained interviewers administered surveys from January 2001 to March 2003. All participants
provided written informed consent and were compensated for their time. The NSAL response rates
ranged from 70.7% among African Americans to 77.7% among Caribbean Blacks. Population-based
sampling weights were calculated to minimize potential bias related to unequal probability of selection
and participant non-response; the weights included a post-stratification correction to allow researchers
to provide generalizable estimates of psychiatric disorder prevalence for Black Americans [41].



Int. J. Environ. Res. Public Health 2020, 17, 7007 6 of 22

3.2. Ethics

The NSAL was conducted in accordance with the Declaration of Helsinki and the Institutional
Review Board at the University of Michigan approved the study protocol (IRB: B03-00004038-R1).
The NSAL data are publicly available through the Interuniversity Consortium for Political and Social
Research (ICPSR): https://www.icpsr.umich.edu/web/ICPSR/studies/20240/datadocumentation.

3.3. Participants

Of the 6072 participants in the NSAL who completed surveys, 2299 women were African American
and 978 women were of Caribbean descent. In the present study, we excluded data from 31 African
American women born outside of the U.S. because the small sample size could lead to privacy and
confidentiality concerns, as well as unstable estimates. We also excluded data from 26 African American
women and 9 Caribbean Black women due to missing nativity status. The final analytic sample for
this study included 2242 U.S.-born African American women, 264 U.S.-born Caribbean Black women,
and 705 foreign-born Caribbean Black women.

3.4. Measures

3.4.1. Ethnicity and Nativity

Participants self-reported their race, ancestry or ethnicity, and country of birth. Utilizing rules
for racial or ethnic classification from the U.S. Census, we created three groups: U.S.-born African
American, U.S.-born Caribbean, and foreign-born Caribbean women. This allowed us to examine not
only the role of race in mental health prevalence, persistence, and unmet needs, but also the roles
that ethnicity and nativity might contribute to these clinical and public health concerns. U.S-born
Caribbeans included women who identified as Black, reported ancestral ties to a Caribbean country,
and reported being born within the U.S. The foreign-born group included Caribbean Black women
who reported being born in a country other than the U.S.

3.4.2. Psychiatric Disorder Prevalence

The presence of probable lifetime and twelve-month psychiatric disorders was assessed using the
World Mental Health version of the World Health Organization’s Composite International Diagnostic
Interview (WHO-CIDI) [19,42]. The WHO-CIDI is a fully structured interview used to assess the
prevalence of DSM-IV psychiatric disorders. In this study, the focus was the examination of three
mood disorders (i.e., major depressive disorder, dysthymia, bipolar disorders I and II), five of the
DSM-IV anxiety disorders (agoraphobia, PTSD, social phobia, general anxiety disorder, panic disorder),
and four of the substance use disorders (alcohol abuse, alcohol dependence, drug abuse, and drug
dependence). We also estimated the lifetime and twelve-month prevalence for panic attacks.

3.4.3. Persistence of Disorders

We classified each psychiatric disorder as being persistent or not. As in other studies, persistence
was defined as the proportion of adults with a lifetime psychiatric disorder who continued to meet
diagnosis criteria in the twelve months that proceeded their interview date [34,43]. Our persistence
analysis focused on the subsample of 874 African American and Caribbean Black women who (1) met
criteria for a lifetime psychiatric disorder and (2) reported an age of onset at least two years prior to the
date of their interview [35]. This measure is a proxy for identifying those with a disorder lasting more
than twelve months [22,34]. The examination of persistence could illustrate how race combined with
other statuses may be a factor in the experience of psychiatric disorders.

https://www.icpsr.umich.edu/web/ICPSR/studies/20240/datadocumentation


Int. J. Environ. Res. Public Health 2020, 17, 7007 7 of 22

3.4.4. Mental Health Service Utilization

Participants in the study were coded as having a lifetime of mental health service utilization if
they selected any response that indicated that they had sought help for nerves, emotions, mental health,
or use of alcohol or drugs from a medical provider (i.e., general practitioners), medical specialist
(e.g., cardiologist), medical professionals (e.g., nurse), or mental health provider (i.e., psychologist,
psychiatrist, counselor, or social worker in a mental health setting). We coded participants as positive
for lifetime mental health service utilization if they affirmed seeking help from a medical or mental
health provider at any time during their lifetime. Similarly, we coded participants as positive for
twelve-month service utilization if they sought help from a medical or mental health provider in the
twelve months prior to the interview.

3.5. Statistical Analysis

We conducted analyses in four steps. In the first step, we used design-adjusted cross-tabulations
to determine the lifetime and prior twelve-month prevalence estimates of each of the measured mood,
anxiety, and substance use disorders; the persistence of those disorders; and mental health service use
across the three subgroups of Black women. As in prior work, the percentages here are weighted study
proportions and the standard errors account for the complex survey design [35].

In the second step, we used multivariable logistic regressions to estimate differences in the
prevalence of psychiatric disorders (lifetime and twelve-month disorders) among women varying
in U.S. nativity and Caribbean heritage. In these analyses, we ran one set of models to compare the
adjusted odds of meeting the DSM-IV disorder criteria for the Black Caribbean groups compared to
African American women. Then, we ran another set of models to evaluate nativity differences in the
adjusted odds of meeting the DSM-IV criteria within the Caribbean Black sample (i.e., the African
Americans were excluded). The prevalence analyses, run separately for the lifetime and twelve-month
disorders, controlled for sociodemographic characteristics shown in prior research to correlate with risk
for a psychiatric disorder [43]: age, household income, poverty status (a ratio of family income to the
U.S. census poverty threshold in 2001), education, employment status, marital status, and geographic
region of the U.S.

In the third step, we used multivariable logistic regression analyses to test for differences in the
persistence of each measured disorder among women varying in U.S. nativity and Caribbean heritage.
As described above, the sample was restricted to participants whose disorder began at least two years
prior to the interview. The first set of models compared the odds of meeting the twelve-month criteria
for a disorder among the Black Caribbean groups compared to U.S.-born African American women.
In the second set of models that excluded African Americans, we evaluated nativity differences among
Caribbean Black women. The persistence analyses controlled for participant characteristics thought
to contribute to a more chronic or persisting course of disorder [44–49]: age (18–30, 31–50, 51+),
education (high school or less vs. other), marital status (married vs. other), poverty status (household
income below 100% federal poverty level vs. other), and age of disorder onset [34,35].

In the fourth step, we used multivariable logistic regressions to test for group differences in the
likelihood of mental health service use among those who met lifetime and twelve-month criteria for
each mood, anxiety, and substance use disorder. As with the prevalence and persistence analyses
above, we first ran the models to test for ethnicity-related differences in the odds of seeking mental
health services, and then ran the models to test for nativity-related differences. The models of mental
health service use each controlled for predisposing, enabling, and need factors, which are commonly
associated with patients’ access to and use of mental health services [50–52]: age (18–30, 31–50, 51+),
education (high school or less vs. other), marital status (married vs. other), poverty status (household
income below 100% federal poverty level vs. other), and insurance status at the time of the interview.

All statistical analyses were conducted in SAS (9.1, SAS Institute Inc., Cary, NC, USA),
included survey weights to provide population-generalizable estimates, and estimated variances
according to the complex sampling design of the NSAL [53]. The survey weights were calculated



Int. J. Environ. Res. Public Health 2020, 17, 7007 8 of 22

to account for the unequal probability of selection and survey response and for post-stratification.
The standard errors for estimates in the Black Caribbean groups were often larger than the standard
errors for estimates among African American women because the Caribbean Black sample was smaller
and more clustered than the African American sample.

4. Results

Characteristics of the sample are presented in Table 2. Compared to African American women,
U.S.-born Caribbean Black women were younger and reported higher average household incomes.
Additionally, U.S.-born Caribbean Black women, as compared to African American women, tended to
report higher levels of education and were less likely to live in households where income was
below the federal poverty level. Consistent with U.S. residential patterns, a greater proportion of
African American women resided in the South compared to both groups of Caribbean Black women.
The women did not differ significantly in their current employment, marital, or insurance status.

Table 2. Sociodemographic Characteristics of Black Women in the National Survey of American
Life, 2001–2003.

African American Caribbean Black

Sociodemographic Characteristics
U.S.-Born (n = 2242) U.S.-Born (n = 264) Foreign-Born (n = 705)

Weighted % (S.E.) X2

Age
18–29 24.4 (1.2) 42.9 (4.9) 19.5 (2.7)
30–44 34.5 (1.2) 32.7 (4.4) 41.2 (3.0)
45–59 23.8 (1.0) 10.2 (1.9) 23.4 (3.5)

60 or greater 17.3 (1.1) 14.2 (4.8) 15.9 (2.1) 25.837 ***
Income

Less than $18,000 37.2 (1.5) 24.8 (4.1) 25.0 (3.1)
$18,000–31,999 26.4 (1.2) 28.6 (3.5) 29.8 (3.7)
$32,000–54,999 20.2 (0.9) 17.7 (4.3) 23.5 (3.7)

$55,000 or greater 16.2 (1.3) 28.9 (6.8) 21.7 (3.8) 19.011 **
Employment Status

Working 62.9 (1.4) 69.6 (4.6) 71.4 (4.4)
Not Working 37.1 (1.4) 30.4 (4.6) 28.6 (4.4) 5.090
Marital Status

Currently Married 35.0 (1.3) 34.3 (6.3) 43.7 (4.7)
Previously Married 32.3 (1.0) 22.3 (5.5) 30.1 (4.8)

Never Married 32.7 (1.5) 43.5 (4.0) 26.2 (2.3) 8.926
Education

Less than High School 25.1 (1.8) 15.8 (5.3) 22.9 (2.9)
High School 36.6 (1.3) 26.6 (5.3) 32.5 (2.3)

Some College 24.7 (1.1) 38.1 (5.4) 24.3 (3.1)
College 13.6 (1.2) 19.5 (3.4) 20.3 (2.5) 18.568 **

Poverty Status
In Poverty 29.3 (1.4) 21.9 (4.2) 19.0 (2.5)

Not in Poverty 70.7 (1.4) 78.1 (4.2) 81.0 (2.5) 11.851 **
Geographic Region

South 55.6 (2.3) 24.2 (7.1) 27.8 (6.3)
Non-South 44.4 (2.3) 75.8 (7.1) 72.2 (6.3) 27.340 ***

Insurance Status
Insured 82.6 (1.3) 80.8 (6.0) 80.0 (3.3)

Uninsured 17.4 (1.3) 19.2 (6.0) 20.0 (3.3) 0.548
Citizenship
U.S. Citizen 63.4 (3.5)

Non-U.S. Citizen 36.6 (3.5)

Abbreviations: U.S. = United States; S.E. = standard error. Note: ** p < 0.01, *** p < 0.001.

4.1. Lifetime Prevalence of Mood, Anxiety, and Substance Use Psychiatric Disorders

Approximately one-third of the U.S.-born African American and Caribbean women met criteria
for a lifetime mood, anxiety, or substance use disorder, while only one in five foreign-born Caribbean
women met such criteria (see Table 3, below). Approximately half of Black women born in the U.S
with a lifetime disorder also met the criteria for a second lifetime disorder.



Int. J. Environ. Res. Public Health 2020, 17, 7007 9 of 22

Table 3. Weighted prevalence of lifetime DSM IV/WMH-CIDI mood, anxiety, and substance use psychiatric disorders among black women in the National Survey of
American Life.

Lifetime DSM-IV Disorders Twelve-Month DSM-IV Disorder

African American Caribbean Black African American Caribbean Black

DSM-IV Disorder
U.S.-Born
(n = 2242)

U.S.-Born
(n = 264)

Foreign-Born
(n = 705)

U.S.-Born
(n = 2242)

U.S.-Born
(n = 264)

Foreign-Born
(n = 705)

Weighted % (S.E.) Weighted % (S.E.)

Mood Disorders
Major Depressive Disorder 14.4 (0.8) 22.6 (5.7) 11.2 (2.0) b 8.2 (0.5) 7.5 (1.8) 7.0 (2.1)

Dysthymia 4.3 (0.5) 1.9 (0.7) a 2.7 (1.1) 3.2 (0.5) 0.7 (0.4) a 0.4 (0.2) a

Bipolar Disorder I, II c 1.4 (0.3) 0.9 (0.8) 1.0 (0.6) 1.0 (0.3) 0.7 (0.8) 0.5 (0.2)
Any Mood Disorder 14.8 (0.8) 22.6 (5.7) 11.4 (2.0) b 8.5 (0.5) 7.5 (1.8) 7.2 (2.1)
Anxiety Disorders

Agoraphobia 2.4 (0.4) 4.7 (3.7) 1.8 (0.8) b 1.5 (0.2) 0.7 (0.4) 1.1 (0.7)
Post-traumatic Stress Disorder 12.2 (0.8) 9.9 (2.0) 7.8 (1.5) a 4.9 (0.5) 3.8 (1.2) 3.0 (1.1)

Social Phobia 8.3 (0.8) 5.4 (2.2) 5.1 (1.2) 5.5 (0.6) 3.6 (1.3) 4.6 (1.1)
General Anxiety Disorder 5.6 (0.6) 6.8 (2.4) 3.1 (1.1) 3.2 (0.5) 2.5 (1.6) 1.4 (0.7)

Panic Disorder 4.4 (0.5) 4.1 (1.2) 2.5 (1.0) 3.1 (0.4) 2.4 (0.9) 0.8 (0.3) a

Panic Attack 24.7 (1.0) 29.6 (3.9) 17.5 (3.3) a,b 10.8 (0.8) 20.3 (4.8) a 7.8 (2.0) b

Any Anxiety Disorder 24.0 (1.1) 23.3 (4.1) 13.8 (1.7) a 13.8 (0.9) 9.5 (2.5) 8.0 (1.4) a

Substance Use Disorders
Alcohol Abuse 5.2 (0.7) 4.6 (1.8) 0.6 (0.9) a,b 1.2 (0.3) 0.4 (0.4) 0.2 (0.1) a,b

Alcohol Dependence c 2.5 (0.4) 2.6 (1.7) 0.2 (0.1) a,b 0.9 (0.3) 0.0 (0.0) a 0.1 (0.1) a,b

Drug Abuse 3.3 (0.5) 4.5 (1.8) 0.6 (0.2) a,b 1.0 (0.2) 1.2 (0.2) 0.1 (0.1) a,b

Drug Dependence 1.3 (0.3) 2.3 (0.9) 0.4 (0.2) a,b 0.3 (0.1) 0.5 (0.5) 0.1 (0.1)
Any Substance Use Disorder 6.5 (0.7) 5.8 (1.8) 1.0 (0.3) a,b 2.1 (0.4) 1.6 (0.4) 0.3 (0.1) a,b

Any of the Above Disorders 32.4 (1.1) 33.8 (5.5) 19.5 (2.1) a,b 18.6 (0.9) 14.1 (3.4) 12.8 (2.1)
2 or More of the Above Disorders 15.4 (0.8) 17.3 (3.6) 8.3 (1.3) a 7.8 (0.7) 5.9 (1.4) 3.0 (0.8) a

Abbreviations: DSM IV = Diagnostic and Statistical Manual of Mental Disorders, 4th edition; WMH-CIDI = World Mental Health version of the World Health Organization’s Composite
International Diagnostic Interview; U.S. = United States; S.E. = standard error. Pairwise comparisons of ethnic and nativity differences in the prevalence of psychiatric disorders obtained
from multivariable logistic regressions. a Adjusted odds of meeting disorder criteria, compared to African American women, was statistically significant at p < 0.05. b Adjusted odds of
meeting disorder criteria, compared to U.S.-born Caribbean women, was statistically significant at p < 0.05. c Multivariate pairwise comparisons of ethnic or nativity differences in the
12-month prevalence of specific disorders were not conducted due to the small samples.



Int. J. Environ. Res. Public Health 2020, 17, 7007 10 of 22

The patterns of differences in the prevalence of any lifetime disorder were largely mirrored
when mood, anxiety, and substance use disorders were considered separately. In the overall sample,
15% of Black women met criteria for a lifetime mood disorder, 25% for a lifetime anxiety disorder,
and 6% for a lifetime substance use disorder. With only one exception (i.e., dysthymia), there were no
statistically significant differences in the rate of lifetime disorders between African American women
and Caribbean women born in the U.S. However, foreign-born Caribbean women, compared to African
Americans or U.S.-born Caribbeans, had a lower lifetime prevalence of major depressive disorder,
agoraphobia, PTSD, panic attack, and each of the measured substance use disorders. Only 1% of
foreign-born Caribbean women met the criteria for any lifetime substance use disorder.

4.2. Twelve-Month Prevalence of Mood, Anxiety, and Substance Use Psychiatric Disorders

Approximately one out of five African American women and one out of seven Caribbean women
in this population-representative study met criteria for a psychiatric disorder in the twelve months
prior to the interview (Table 3). Of those, about half of African American women and one-quarter of
foreign-born Caribbean women met the criteria for two or more disorders in the preceding twelve
months. There were no statistical differences between groups in the prevalence of having at least
one psychiatric disorder in the past twelve months. However, the prevalence of having two or
more psychiatric disorders in the preceding twelve months was higher in African American women
compared to foreign-born Caribbean women.

For Black women in general, the prevalence of meeting the criteria for a psychiatric disorder in the
prior 12 months was 8% for a mood disorder, 14% for an anxiety disorder, and 2% for a substance use
disorder. There were some ethnic variations in the prevalence of specific mood, anxiety, and substance
use disorders in the past 12 months. Compared to African American women, U.S.-born Caribbean
women were less likely to meet criteria for dysthymia or alcohol dependence, but more likely to meet
the criteria for panic attacks. In addition, African American women had a higher prevalence compared
to foreign-born Caribbean women of dysthymia, panic disorder, any anxiety disorder, alcohol abuse,
alcohol dependence, drug dependence, and any substance use disorder.

Within the Caribbean samples, foreign-born Caribbean women were less likely than U.S.-born
Caribbean women to meet recent criteria for panic attacks, alcohol abuse or dependence, and drug
abuse. We were unable to obtain adjusted group differences in the prevalence of bipolar I/II or drug
dependence between the U.S. and foreign-born Caribbean Black women due to the very low prevalence
of these disorders in each of the Caribbean groups.

4.3. Persistence of Mood, Anxiety, and Substance Use Psychiatric Disorders in Black Women in the U.S.

Over half of the women who met criteria for a lifetime psychiatric disorder were also classified
as having a persistent disorder (Table 4). The percentage of disorders classified as being persistent
was highest for anxiety (57.4%) and mood disorders (51.5%) and lowest for lifetime substance use
disorders (29.7%). Among the three groups, foreign-born Caribbean women had the highest percentage
of persistent disorders. They were more likely than U.S.-born Caribbean women to still meet DSM-IV
criteria for any disorder in the past twelve months.

The patterns of ethnic and nativity differences in psychiatric persistence varied somewhat by
disorder. African American women were more likely than both groups of Caribbean women to continue
to meet DSM-IV criteria in the twelve months prior to the interview for dysthymia. African American
women were less likely than foreign-born Caribbean women to continue to meet criteria for bipolar I/II
or social phobia in the prior twelve months; but more likely than foreign-born Caribbean women to
meet persistence criteria for panic disorder.

Within the Caribbean sample, foreign-born women were less likely than U.S.-born Caribbean
women to meet criteria for panic attack and drug dependence in the past year; they were more likely to
still meet criteria for any anxiety disorder, alcohol abuse, and alcohol dependence. We were unable



Int. J. Environ. Res. Public Health 2020, 17, 7007 11 of 22

to estimate nativity differences in the adjusted odds of persisting bipolar disorder I/II due to sparse
numbers of Caribbean women meeting criteria in the past 12 months.

4.4. Lifetime Utilization of Mental Health Services

Two-thirds (66%) of Black women who met criteria for at least one of the measured psychiatric
disorders also indicated that they had sought help from a general medical provider or a specialty
mental health provider at some point during their lifetime. Among the entire sample, 72% of those
with a lifetime mood disorder reported having used mental health services, which was similar to the
portion of Black women with an anxiety disorder (68%) or a substance use disorder (69%).

Comparisons of mental health service use among the three groups of Black women revealed
several significant differences (Table 5). Among women with any lifetime disorder, U.S.-born Caribbean
women had the highest prevalence of lifetime mental health service use. This pattern was also observed
for the subsample of women with two or more lifetime disorders, as well as for those with any mood,
anxiety, or substance use disorder. In addition, U.S.-born Caribbean women had higher rates of
lifetime mental health service use compared to African American women with diagnoses of major
depressive disorder, bipolar I/II, social phobia, generalized anxiety disorder, and each of the substance
use disorders.

Table 4. Proportion of Black women with a lifetime DSM-IV mood, anxiety, and substance use
psychiatric disorder who met the criteria for a psychiatric disorder in the past 12 Months.

African American Caribbean Black

DSM-IV Disorder
U.S.-Born U.S.-Born Foreign-Born

N Weighted % (S.E.)

Mood Disorders
Major Depressive Disorder 370 51.8 (2.9) 29.4 (9.2) 58.9 (12.2)

Dysthymia 105 73.1 (5.4) 37.6 (14.5) a 14.0 (5.2) a

Bipolar Disorder I, II c 25 70.5 (9.6) – 100 (0.0) a

Any Mood Disorder 379 52.2 (2.9) 29.4 (9.5) 58.8 (12.0)
Anxiety Disorders

Agoraphobia 75 59.0 (6.6) 13.9 (13.2) 60.2 (16.6)
Post-traumatic Stress

Disorder
287 40.6 (3.3) 38.0 (11.2) 34.5 (10.8)

Social Phobia 223 64.7 (4.0) 64.5 (9.0) 90.1 (5.1) a

General Anxiety Disorder 141 56.1 (5.1) 34.4 (22.8) 44.5 (18.8)
Panic Disorder 124 70.4 (4.7) 54.4 (21.4) 27.2 (11.1) a

Panic Attack 633 41.3 (2.7) 57.0 (12.4) 36.0 (13.2) b

Any Anxiety Disorder 630 57.8 (3.0) 40.3 (10.1) 57.7 (6.3) b

Substance Use Disorders
Alcohol Abuse 132 23.1 (4.2) 8.3 (7.9) 19.9 (10.4) b

Alcohol Dependence 58 36.4 (5.7) – 25.8 (32.5) b

Drug Abuse 90 23.7 (4.8) 26.8 (4.6) 10.6 (12.2)
Drug Dependence 40 23.7 (7.8) 22.9 (18.0) 14.8 (14.2) b

Any Substance Use Disorder 168 29.8 (4.2) 27.7 (9.4) 25.0 (12.3)
Any of the Above Disorders 874 56.1 (2.3) 40.5 (10.7) 64.2 (6.3) b

Abbreviations: DSM IV = Diagnostic and Statistical Manual of Mental Disorders, 4th edition; U.S. = United States;
S.E. = standard error. Pairwise comparisons of ethnic and nativity differences in the persistence of psychiatric
disorders obtained from multivariable logistic regressions. Analyses were restricted to those that first met the
DSM-IV criteria for a lifetime disorder at least two years prior to the interview. a Adjusted odds of meeting
persistence criteria, compared to African American women, was statistically significant at p < 0.05. b Adjusted odds
of meeting persistence criteria, compared to U.S.-born Caribbean women, was statistically significant at p < 0.05. c
Multivariate pairwise comparisons of nativity differences in the persistence of specific disorders were not conducted
due to the small samples.

Within the Caribbean sample, rates of mental health service use were much higher for U.S.-born
Caribbean women compared to foreign-born Caribbean women. This pattern was observed for those
with major depressive disorder, bipolar disorder I/II, any mood disorder, agoraphobia, social phobia,
any anxiety disorder, drug abuse, drug dependence, and any substance use disorder.



Int. J. Environ. Res. Public Health 2020, 17, 7007 12 of 22

4.5. Past-Year Utilization of Mental Health Services

Only one in four Black women (28%) who met criteria for a psychiatric disorder in the twelve
months prior to the survey also reported seeking mental health care services in the twelve months prior
to the interview. Among Black women as a group, 38% of those who met criteria for a mood disorder,
25% of those with an anxiety disorder, and 35% of those with a substance use disorder received services
in the year prior to the interview.

There were only a few ethnic differences in mental health service use in the past twelve months
(Table 5). Specifically, African American women with a past twelve-month disorder of bipolar I/II,
panic disorder, or alcohol abuse had lower rates of recent mental health service use compared to
U.S.-born Caribbean women with the same disorders. Compared to African American women, rates of
mental health service use in the past twelve months were lower for foreign-born Caribbean women with
major depressive disorder, any mood disorder, social phobia, or panic attack; and higher for foreign-born
Caribbean women with bipolar disorder I/II, agoraphobia, alcohol abuse, or alcohol dependence.

In the Caribbean cohort, foreign-born women with any recent disorder were less likely than
U.S.-born Caribbean women to have reported using mental health services in the past year.
These patterns of nativity differences in service utilization were also observed for women with
dysthymia, social phobia, panic attack, or any anxiety disorder. However, the patterns of nativity
differences in mental health service use were reversed for women with substance use disorders;
foreign-born Caribbean women who met criteria for drug abuse or any substance use disorder in
the past twelve months had higher rates of recent mental health service use compared to U.S.-born
Caribbean women with the same diagnoses.

Nativity differences in the adjusted odds of using mental health services could not be estimated
for women with agoraphobia, alcohol abuse, alcohol dependence, or drug dependence due to small
numbers and limited variation in responses. For instance, in the very small samples of Caribbean
women with recent bipolar disorder I/II or alcohol abuse, all U.S.-born women with these diagnoses
reported using mental health services. None of the Caribbean women in our sample who met the
criteria for drug dependence in the past twelve months reported using mental health services in the
prior 12 months.



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Table 5. Weighted percentages of African American vs. U.S.-born and foreign-born Caribbean Black women with a history of a DSM-IV mood, anxiety, or substance
use psychiatric disorder that sought mental health services.

Lifetime Service Use Twelve-Month Service Use

U.S.-Born
African American

Caribbean Black U.S.-Born
African American

Caribbean Black

DSM-IV Disorder
U.S.-Born Foreign-Born U.S.-Born Foreign-Born

N Weighted % (S.E.) N Weighted % (S.E.)

Mood Disorders
Major Depressive Disorder 426 72.4 (2.3) 87.0 (5.3) a 42.2 (11.3) a,b 235 38.9 (3.7) 49.1 (16.3) 13.3 (6.5) a

Dysthymia 108 82.6 (4.3) 56.1 (14.4) 85.3 (5.2) 71 39.5 (7.0) 26.1 (17.6) 11.5 (11.9) b

Bipolar Disorder I, II c 47 90.3 (3.9) 100 (0.0) a 88.7 (6.1) b 32 43.9 (9.7) 100 (0.0) a 67.1 (0.0) a

Any Mood Disorder 441 72.6 (2.3) 87.0 (5.6) a 41.4 (11.0) a,b 246 38.6 (3.6) 49.1 (17.3) 13.1 (6.4) a

Anxiety Disorders
Agoraphobia c 77 60.2 (5.8) 90.4 (10.1) 10.6 (7.8) a,b 46 6.7 (4.1) – 12.3 (10.9) a

Post-traumatic Stress Disorder 331 73.9 (3.2) 87.1 (6.5) 58.6 (10.0) 134 26.0 (5.4) 33.7 (19.5) 12.4 (6.7)
Social Phobia 228 64.0 (3.5) 88.9 (8.1) a 43.8 (15.6) b 158 22.6 (3.4) 56.5 (19.9) 5.2 (3.2) a,b

General Anxiety Disorder 148 73.8 (4.6) 98.5 (1.6) a 69.5 (18.4) 80 34.3 (6.4) 11.5 (10.8) 18.9 (11.8)
Panic Disorder 131 82.5 (4.4) 90.6 (9.1) 90.9 (6.3) a 92 32.1 (7.0) 51.1 (12.0) a 20.1 (11.9)
Panic Attack 715 62.0 (3.0) 64.9 (10.4) 45.4 (13.8) 346 30.9 (3.1) 47.8 (15.8) 10.7 (5.3) a,b

Any Anxiety Disorder 662 67.9 (2.5) 89.9 (4.2) a 58.4 (8.1) b 383 25.3 (2.4) 33.9 (11.1) 12.6 (4.4) b

Substance Use Disorders
Alcohol Abuse c 140 65.3 (4.9) 95.9 (2.1) a 72.7 (13.6) 35 13.5 (6.5) 100 (0.0) a 54.8 (0.0) a

Alcohol Dependence c 59 75.7 (6.0) 100 (0.0) a 100 (0.0) a 19 33.0 (10.8) – 100 (0.0) a

Drug Abuse 97 71.7 (5.4) 98.1 (2.0) a 71.9 (10.7) b 27 46.5 (10.6) 15.0 (6.4) 50.7 (25.0) b

Drug Dependence c 40 81.6 (3.9) 100 (0.0) a 85.2 (14.2) a,b 9 48.2 (8.4) – –
Any Substance Use Disorder 175 67.9 (4.4) 96.8 (1.7) a 68.4 (13.7) b 56 34.5 (6.9) 35.3 (13.6) 44.2 (12.1) b

Any of the Above Disorders 933 65.5 (1.9) 85.7 (4.5) a 47.0 (8.6) b 536 28.8 (2.3) 33.6 (10.3) 12.1 (4.2) a,b

2 or More of the Above Disorders 432 75.6 (2.9) 92.7 (4.1) a 63.9 (8.4) b 209 33.1 (3.3) 49.9 (10.3) 20.4 (6.3)

Abbreviations: DSM IV = Diagnostic and Statistical Manual of Mental Disorders, 4th edition; U.S. = United States; S.E. = standard error. Pairwise comparisons of ethnic and nativity
differences in the likelihood of seeking mental health services, obtained from multivariable logistic regressions. a Adjusted odds of mental health service use, compared to African
American women, was statistically significant at p < 0.05. b Adjusted odds of mental health service use, compared to U.S.-born Caribbean women, was statistically significant at p < 0.05.
c Multivariate pairwise comparisons of nativity differences in twelve-month service use could not be estimated due to small samples and lack of variation in service use. Note: – indicates
that weighted estimates could not be obtained because none of the lifetime cases reported using mental health services.



Int. J. Environ. Res. Public Health 2020, 17, 7007 14 of 22

5. Discussion

This study sought to illuminate the diverse mental health needs of Black women in the U.S. by
combining information on the prevalence, persistence, and treatment utilization patterns of women
varying in ethnic background and country of birth. An additional goal was to determine if Black
women, similar to Black men, experienced substantial persistence of mental health and substance use
disorders when prevalence criteria were met. Indeed our results do call attention to the fact that similar
to Black men [35], one-half of Black women with a disorder suffer from persistence of that disorder.
In the U.S., this is compounded by the fact that some Black women are not seeking treatment for these
disorders [23], which puts them at risk for the consequences of untreated mental health.

5.1. Patterns of Differences in Mental Health Disorder Prevalence

Our findings build on prior literature by presenting estimates of lifetime and twelve-month rates
of specific mood, anxiety, and substance use disorders for foreign-born Caribbean women to better aid
mental health services planning for this growing population. Consistent with studies of mental health
and substance use among African and Caribbean immigrants carried out in other countries [54–57],
we found Black women who have migrated from the Caribbean had lower rates of psychiatric disorders
than Black women born in the U.S., especially for substance use disorders. These results are consistent
with the healthy immigrant literature, which finds that foreign-born populations often have better
health and mental health outcomes [13,16,54,57–61]. In addition, this study contributes to the literature
by demonstrating the chronic course of mental health and substance use disorders, such as dysthymia
and panic disorder in African American women, which appear to persist even for women who have
accessed mental health services during the lifetime.

5.2. Understanding Differences in Psychiatric Disorder Persistence

Our findings of differences in the persistence of disorders based on U.S. versus foreign-born
nativity does not fully align with the healthy immigrant literature—a finding that may be less true for
conditions of mental health. The rates of persistence were generally comparable for the foreign-born
Caribbean women and U.S.-born African American women. It was the U.S.-born Caribbean women
who, except for panic attacks and drug dependence, stood out as having particularly low rates of
persistence. Foreign-born Caribbean women had the highest rate of persisting social phobia. We might
expect persistence to be lower among U.S.-born Caribbean Black women if they are differentially
exposed to stressors commonly associated with mental illness or if there are differences in the amount,
quality, or access to mental health treatment. Another possible explanation is that Caribbean Black
women differentially weather stressors. One NSAL study found more social stressors to be associated
with higher rates of depressive symptoms for African American women than for Caribbean Black
women [31]. In our study, the U.S.-born Caribbean women generally had more favorable socioeconomic
standing in terms of their education and household income compared to African American women,
which could be another contributing factor to the differences in persistence we see [62].

Two unique issues are raised by our findings of ethnic and nativity differences in persistence.
First, it is assumed that the marginalized position of being Black in the U.S. will result in greater
exposure to stressors often shown to be associated with worse mental health outcomes [63–65]. Yet there
is something about the social patterning of race plus nativity that results in differences in mental
health experience, as well as in seeking treatment. The advantage of household income and education
may confer resources to better weather stresses and potentially results in fewer cumulative exposures.
The U.S.-born Caribbean women may be unique from the other groups of Black women in their
available resources or in the urgency or intensity of treatment when a mental health problem arises.
Indeed, in the current study, U.S.-born Caribbean women had higher rates of lifetime mental health
service use, even when compared to African American women. This raises a second point in need of
further research, which is that differences in cultural socialization between being Black in the U.S. versus



Int. J. Environ. Res. Public Health 2020, 17, 7007 15 of 22

early socialization of mental health coping in the foreign-born Black woman. Additional research into
mental health coping and other resources to weather stressors could inform the design of interventions
to address unmet treatment needs within various groups of Black women in the U.S.

5.3. Implications for Mental Health Services

In our study, foreign-born Caribbean women had the lowest rates of treatment utilization,
whether across the lifetime or within the twelve months prior to the interview. These findings parallel
those for Latino and Asian immigrants [66,67]. Immigrants often face additional barriers to treatment
due to residency status or concerns about bringing shame to their community [68]. A few studies
have documented high rates of mental health stigma among Caribbean immigrants [69,70], which may
contribute to their low rates of treatment seeking. Whether these barriers have a differential harmful
impact on Caribbean women is unknown. Because untreated mental health disorders are so closely
linked to cardiovascular disease and metabolic disorders [71–74], failure to engage Caribbean women
in evidence-based mental health treatment is likely to have cascading consequences for not only their
emotional health, but for their physical health as well.

There were more statistical differences in the rate of treatment across the lifetime than in the twelve
months prior to the interview. Part of this may be due to the smaller sample size (and thus larger
standard errors) that accompanied the twelve-month analyses. However, it could also be the case that
there are differences in the time to treatment or in the length or quality of treatment, which may explain
the different patterns of results. Unfortunately, we do not know, and this is an area for further study.
A majority of the population-based studies involving Black Americans that have examined the time
to treatment [75], the quality of treatment received [76], or treatment retention [22,77] have focused
on Black vs. White differences and have not examined the experiences of Caribbean immigrants.
One study from the NSAL found that Caribbean migrants had more favorable mental health service
experiences compared to U.S.-born Caribbeans [78], but these findings were not reported specifically
for Black women.

The results of our analyses indicate that there are cultural differences in several factors, such as the
tendency to seek care, chronicity in different disorders, and prevalence of these disorders. Those primary
care practices that reside in neighborhoods whose patient populations contain a number of Black
women should ensure that they are collecting subgroup ethnicity and nativity data so that they can
respond adequately to differences in mental health needs among Black women. It will not be adequate
for clinics and health care systems to merely know that their populations are Black, but knowing
patients’ ethnicity and nativity may be useful in anticipating and designing effective care for mental
health and substance use problems.

5.4. Study Limitations

This study has four primary study limitations. First, the prevalence rates presented here only
generalize to non-institutionalized Black women. African American women are more likely than White
women to be represented in the prison system [37] and rates of psychiatric disorders are much higher
among incarcerated women than community samples [79,80]. Therefore, our prevalence estimates
from a household-based sample underestimate the burden of mental illness among Black women in
the U.S. as well as their unmet need for treatment.

Second, there is evidence from the clinical reappraisal studies that the WHO-CIDI did not perform
equally well in identifying psychiatric disorders across ethnic groups in the NSAL. The evidence
suggests that the WHO-CIDI picked up a larger portion of false positive cases among the Caribbean
population [24]. Therefore, caution should be exercised in thinking about the prevalence of disorders
reported for Caribbean women as our findings may have overestimated their prevalence and needs.

Third, this study was limited by low statistical power to examine ethnic differences in persistence
or mental health service utilization for some disorders (such as bipolar disorder or alcohol use
disorder) that are less prevalent among Black women. We also were limited by low statistical power



Int. J. Environ. Res. Public Health 2020, 17, 7007 16 of 22

to further examine mental health differences within subgroups of Caribbean women (e.g., different
immigration cohorts or countries of origin), or to estimate mental health disorder prevalence, persistence,
and treatment utilization for foreign-born women emigrating from African countries. Previous studies
have found that immigrants’ mental health varies by country of origin, the disorder being studied,
age at immigration, and time in the U.S.

Finally, the use of data from 2001–2003 raises questions about the generalizability of findings
to the present time. It is likely that the unmet mental health needs of African American and
Black Caribbean women in the U.S. could be higher in 2020 than they were in 2003. For example,
the 2008 economic recession disproportionately affected Black households in the U.S. and may have
contributed to increased mental health disparities [81–84]. Most recently, the coronavirus disease
(COVID-19) pandemic has led to higher death rates in both the elderly and younger groups in the Black
population [85–88]. This is occurring without usual burial and grief relief rituals. The social isolation
policies under COVID-19 are also contributing to reduced income, food insecurity, and deferred
outpatient care, which are all factors in unmet mental health treatment needs [89–95]. In addition,
the Black Lives Matter movement has highlighted the concerns of Black women about their own safety,
as well as that of their male family members, in relation to police shootings.

Despite the age of the study data, there are still several compelling reasons why the NSAL offers
relevant insights for use in current mental health service planning and clinical care. Currently, the NSAL
remains the only data set with enough cases within a representative population sample of Black racial
and ethnic minority adults to conduct meaningful analyses on psychiatric disorders. Before the advent
of the NSAL data set, reliable, nationally representative information on psychiatric disorders for
Black women was scarce or relied on data that could be only abstracted from treatment settings [1].
In light of the historic scarcity of national probability-based data sets on Black mental health, the rising
numbers of suicides in Black Americans, and the worsening of factors that contribute to mental
health, as highlighted by COVID-19 and Black Lives Matter, the NSAL remains the best and most
comprehensive data for the study of representative mental health in the Black female population of the
U.S., despite its age.

5.5. Implications for Future Research

We recommend launching a new population-based study to determine the prevalence, persistence,
and treatment needs of psychiatric disorders in Black women in order to provide updated estimates on
the mental health of Black women following historic events and to illuminate the mechanisms through
which Black women weather economic and social stressors. Critical to extending our findings would
be larger subpopulation samples and assessment of migration characteristics (e.g., age, generational
status) to further investigate the treatment and health service needs of different subpopulations of
Black women. This is particularly important as ours and other studies have indicated significant
differences in help-seeking patterns, perceived need for treatment, and stigma concerns of Caribbean
women compared to U.S.-born African American women [27,69]. Moreover, there has been a surge
in African migration in recent years [11], and the mental health service needs of African immigrants
remain poorly understood from a population-based perspective [1]. As demonstrated in our study,
failure to not separate Black women in terms of ethnicity and place of birth would obscure the true
rates of perceived need and pathways of seeking treatment for U.S.-born African American women
and fail to help us to identify those social and cultural conditions of immigrants adjusting to life in the
U.S. that may put them at risk for psychiatric disorders [96].

6. Conclusions

Despite these limitations, this study makes an important contribution to the field, as it is among
the first to bring together a trifecta of mental health service issues together to identify the mental
health status, persistence of disorders, and unmet treatment needs among a nationally representative
sample of African American women and U.S.-born, and foreign-born Caribbean Black women in



Int. J. Environ. Res. Public Health 2020, 17, 7007 17 of 22

the U.S. While the rates of psychiatric disorders among Black women are lower than the national
estimates of psychiatric disorders in the U.S. from the National Comorbidity Survey Replication [44],
nonetheless for those who do have a disorder there is a public health concern. Our result illustrate
there was wide variation by ethnicity in the prevalence, course, and unmet treatment needs of their
psychiatric disorders. As the U.S. continues to be the number one choice for a growing number of
African and Caribbean women to live and raise their families, researchers and policymakers must
attend to differences in this diversity that will allow us to target prevention efforts and mental health
service planning to the specific needs of these Black subpopulations in the U.S. Results of this study
help to underscore that despite being racially the same, variations in ethnicity and nativity result in
distinctive vulnerabilities and mental health treatment needs.

Author Contributions: V.M.M. and R.J.T. conceived the study. A.L.J., S.D.C. and V.M.M. designed the study and
refined the conceptualization. R.J.T. obtained the data. A.L.J. and S.D.C. oversaw statistical analyses with the help
of J.R. who also assisted with the creation of variables and conducted the statistical analyses. V.M.M. and A.L.J.
wrote the first draft of the manuscript. A.L.J., S.D.C. and R.J.T. participated in the interpretation of results and
their discussion. All authors have read and agreed to the published version of the manuscript.

Funding: The data collection on which this study is based was supported by the National Institute of Mental Health
(NIMH; U01-MH57716), with supplemental support from the Office of Behavioral and Social Science Research at
the National Institutes of Health (NIH) and the University of Michigan. The preparation of this manuscript was
supported by grants from National Institute on Minority Health and Health Disparities (MD 006923), National
Institute of Drug Abuse (DA 20826 DA 15539), National Institute of Mental Health (MH115344), and the National
Center for Advancing Translational Sciences under award numbers UL1TR002538 and KL2TR002539. The contents
of this article do not represent the views of the Department of Veterans Affairs, the National Institutes of Health,
or the United States Government.

Acknowledgments: The authors would like to thank James S. Jackson for his pioneering leadership in designing
the NSAL.

Conflicts of Interest: The authors declare no conflict of interest.

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	Introduction 
	Study Aim 
	Methods 
	Procedures 
	Ethics 
	Participants 
	Measures 
	Ethnicity and Nativity 
	Psychiatric Disorder Prevalence 
	Persistence of Disorders 
	Mental Health Service Utilization 

	Statistical Analysis 

	Results 
	Lifetime Prevalence of Mood, Anxiety, and Substance Use Psychiatric Disorders 
	Twelve-Month Prevalence of Mood, Anxiety, and Substance Use Psychiatric Disorders 
	Persistence of Mood, Anxiety, and Substance Use Psychiatric Disorders in Black Women in the U.S. 
	Lifetime Utilization of Mental Health Services 
	Past-Year Utilization of Mental Health Services 

	Discussion 
	Patterns of Differences in Mental Health Disorder Prevalence 
	Understanding Differences in Psychiatric Disorder Persistence 
	Implications for Mental Health Services 
	Study Limitations 
	Implications for Future Research 

	Conclusions 
	References