An Evolutionary Concept Analysis of Depression in Black Mothers

Abstract

Background:

Depression is a common mental health disorder but can be difficult to diagnose. Its prevalence in Black mothers is nine times the national rate, possibly due to barriers in receiving care. In addition, depression may present differently in this group.

Purpose:

The purpose of this concept analysis was to clarify the concept of depression in Black mothers.

Methods:

Four databases were searched for articles focusing on depression in Black mothers. Rodgers’ Evolutionary Method was used to identify characteristics of depression.

Findings:

Antecedents included discrimination, decreased social support, and single marital status. Attributes included anger, low self-esteem, and self-hate. Consequences included negative mental health outcomes in the child.

Discussion:

Many of the characteristics of depression identified in this concept analysis are prevalent in Black mothers. Mental health screenings should include assessments of these factors, and providers should aid Black mothers in identifying stressors and formulating coping strategies.

Introduction

Depression is a leading cause of disability, with approximately 17 million adults in the United States having at least one depressive episode annually (Ingram et al., 2020; Patel et al., 2023). Treatment for depression accounts for nearly $43 billion in healthcare costs each year (Ingram et al., 2020). To improve treatment and prevention, the causes of depression must be better understood (Ingram et al., 2020). However, depression can be difficult to diagnose due to heterogeneous presentations and risk factors (Kuehner, 2017). Additionally, there is often a long delay between the onset of depressive symptoms and the initiation of treatment due to failure to recognize depressive symptoms, mistakenly associating the symptoms with a physical ailment, ignorance of or inability to access mental healthcare, preference for managing the problem themselves, or unwillingness to accept treatment because of stigma (Dockery et al., 2015; Ingram et al., 2020).

Diagnosed depression is more prevalent among women, occurring almost two times more frequently in women than men (Kang et al., 2020), with the most recent estimate being 13.1% in men and 23.4% in women (Lee, 2023). This difference may be partly explained by women’s increased exposure to adversity, such as gender inequities, sexual abuse, and other forms of violence against women (Kuehner, 2017). Women are also more likely to experience somatic symptoms, such as fatigue, pain, and low energy, and report more atypical symptoms such as increased appetite and hypersomnia (Kuehner, 2017).

In Black women, the prevalence of depression has been estimated to be as high as 27% (McCall et al., 2023). Given that depression is underreported, underdiagnosed, and undertreated in this population, the true prevalence is likely higher (Patel et al., 2023; Quist et al., 2022). Depression in this population also tends to be chronic and severe (Patel et al., 2023). This may be due to the increased likelihood of lower socioeconomic status, gendered racism, and caregiving demands faced by Black women (McCall et al., 2023). Gendered racism is defined as oppression faced by women of color based on the intersectionality of race and gender (Jones et al., 2021). This is typified in the angry Black woman stereotype that characterizes Black women as angry when they express their emotions, or robotic or inhuman when they mask their emotions (Jones et al., 2021). There are also cultural constructs, such as the Superwoman Schema and the Strong Black Woman Schema, which emphasize strength in stressful circumstances and caring for others have been recognized as risk factors for depression (Abrams et al., 2019). The Superwoman Schema focuses on obligations to suppress emotions and appear strong, staying motivated, prioritizing care of others over oneself, and resisting vulnerability (Woods-Giscombe et al., 2016). Similarly, the Strong Black Woman Schema emphasizes independence, resilience, and strength in response to physical and mental hardships and can lead Black women to conceal their trauma in favor of appearing strong (Abrams et al., 2019; Beauboeuf-Lafontant, 2009). These cultural expectations combined with stigma against mental illness, may prevent Black women from seeking mental health treatment for fear of appearing weak or being labeled as crazy (McCall et al., 2023; Woods-Giscombé, 2010). This can lead to coping mechanisms such as the suppression of symptoms and self-silencing (McCall et al., 2023). Black women also face such barriers as access to treatment, lack of health insurance, lack of trust in providers, and lower health literacy (McCall et al., 2023).

Studies conducted with Black mothers have reported depressive symptoms in as many as 70% of the participants, which is approximately nine times the national rate of depression (Atkins, 2017). Black mothers are disproportionately impacted by lower income, lower education, being single mothers, and bearing the financial burden for families (Siefert et al., 2007). Black mothers also experience a higher prevalence of food insecurity, the limited or uncertain ability to acquire acceptable foods, which has been associated with depression (Laraia et al., 2009). Alarmingly, approximately 30% of Black children are living in food insecure homes (Laraia et al., 2009). Black mothers with depression are significantly more likely to report behavioral problems in their children, such as temper tantrums, difficulty in social situations, poorer academic performance, or unhappiness or fear in the child (Atkins, Kelly, et al., 2020; Siefert et al., 2007).

Current depression screening methods are not culturally tailored to Black mothers and may fail to identify sufferers in this population (McCall et al., 2023). To understand depression in Black mothers and improve diagnosis and treatment, the attributes, antecedents, and consequences must be clarified. Therefore, the goal of this concept analysis that is grounded in Rodgers’ Evolutionary Model (or Method) is to explore and describe depression and how it specifically presents in Black mothers. This analysis is necessary because concepts are essential for knowledge development and the facilitation of communication between patients and providers (Rodgers, 1989). When the attributes of a concept are unclear, it is difficult to identify instances of that concept, in this case, Black mothers presenting with depression (Rodgers, 1989). This concept analysis will contribute to the nursing literature by clarifying the antecedents and attributes of depression in Black mothers and facilitating providers’ improved recognition of depression or the risk of depression in this population.

Methods

Concept Analysis Model

Rodgers’ Evolutionary Method was used to inform the analysis of depression in Black mothers (Rodgers, 1989). Six steps comprise this method: 1) identify the concept of interest, 2) identify an appropriate setting for data collection, 3) collect data to identify the antecedents, attributes, and consequences of the concept, 4) analyze the data regarding these characteristics, 5) identify an exemplar of the concept, if appropriate, and 6) identify implications and directions for further development of the concept (Rodgers & Knafl, 2000). This method was chosen because Rodgers posits that concepts are influenced by the context of their usage (Tofthagen & Fagerstrøm, 2010). In addition, concepts change over time; they are identified by situations or phenomena rather than a fixed set of conditions (Rodgers, 1989). The three important aspects of the process of concept development are significance, use, and application (Rodgers, 1989). A significant concept serves a purposeful goal, contributes to solving a problem, and adequately characterizes the phenomenon in question (Tofthagen & Fagerstrøm, 2010). The use or context of a concept depends on the culture and discipline and may be influenced by nursing or medicine or the provider’s education (Tofthagen & Fagerstrøm, 2010). Through repeated use, a concept becomes associated with a particular context, and this application determines the scope of the concept (Rodgers, 1989). Application aids in refining a concept over time and introducing variations (Rodgers, 1989).

Search Strategy

A literature search without limits on publication year was conducted in November 2023 in the Pubmed, Scopus, Medline, and PsycInfo databases using the following key words: depression, depressive symptoms, Black, African American, women, and mothers. Included articles focused on depression or depressive symptoms in Black mothers and were written in English in the United States. Articles were excluded if they examined depression related to a chronic illness, such as lupus, HIV, osteoarthritis, or diabetes, or if they focused on women with a history of sexual trauma or intimate partner violence; these factors have been shown to have their own significant associations with depression (Skrine Jeffers et al., 2021; Stockman et al., 2015). In addition, excluded articles included participants with other mental health disorders, included adolescent participants, focused on how the mother’s depression affected the children, or evaluated depression during pregnancy or the postpartum period. This analysis aimed to examine characteristics of depression that were not influenced by these factors.

Findings

Search Results

The database searches yielded 3,678 articles with 2,317 remaining after deduplication (Figure 1). After applying exclusion criteria, 2,272 articles were excluded, leaving 45 for full-text review. Of these, 28 articles were excluded for the following reasons: they were review articles (n = 4), focused on the children and did not report on the mothers (n =2), included women with a history of sexual trauma (n = 2) or intimate partner violence (n = 8), focused on adolescent mothers (n = 1), or did not focus on American women (n = 5). A total of 17 articles remained for inclusion in this analysis (Table 1). All studies were conducted in the United States, and study designs were cross-sectional (n = 12), longitudinal (n = 2), qualitative (n = 2), or case series (n = 1). The most used instruments to screen for depression were the Center for Epidemiologic Studies – Depression Scale (n = 6) and the Beck Depression Inventory (n = 6). Other measures included the Brief Symptom Inventory (n = 1) and Depression Cognition Scale (n = 1) in combination with other instruments and an updated version of the Beck Depression Inventory (n = 1). Three studies assessed depression using a single open-ended question: “What do you do to feel better when you are feeling down in the dumps?” (Atkins, 2016).

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Flow Diagram

Table 1.

Study Characteristics

Study Title/Author	Study Design	Population	Inclusion Criteria	Exclusion Criteria	Depression Screening Instrument
Validation of the Center for Epidemiologic Studies Depression Scale in Black Single Mothers (Atkins, 2014)	Cross-sectional	Convenience sample of Black single mothers from the community, aged 18 to 45 years	Single mothers either never married, widowed, divorced, or separated; one or more children living with them	Currently being treated for a psychiatric disorder, taking antidepressant medications, pregnant, children under one year old	Center for Epidemiologic Studies – Depression Scale
Depression in Black Single Mothers: A Test of a Theoretical Model (Atkins, 2015)	Case series	Convenience sample of 208 Black single mothers	Aged 18 to 45 years; self-identified as Black; widowed, divorced, separated, or never married; children live with them, physically and mentally capable of participating in the study; able to read and understand English	Currently receiving psychiatric treatment or counseling, taking antidepressants, pregnant, children younger than one year old	Center for Epidemiologic Studies – Depression Scale
Coping With Depression in Single Black Mothers (Atkins, 2016)	Qualitative	Community-residing Black single mothers between ages 18 and 45	18 to 45 years old; self-identified as Black; children living with them; widowed, divorced, separated, or never married; physically and mentally able to participate; could read and understand English	Taking antidepressants, receiving psychiatric care or therapy, pregnant, children under one year of age	A single open-ended question
Outcomes of Depression in Black Single Mothers (Atkins, 2017)	Cross-sectional	Single mothers between ages 18 and 45 who self-identified as Black	Never married, widowed, divorced, or separated; at least one child living with them; physically and mentally able to participate in the study, able to read and comprehend English	Presently undergoing psychiatric treatment, taking antidepressants, had a child under one year of age	Center for Epidemiologic Studies – Depression Scale; Depression Cognition Scale
Exploring Expressions of Depression in Black Single Mothers (Atkins et al., 2018)	Cross-sectional	Convenience sample of 210 Black single mothers ages 18 to 45 residing in urban communities	Self-identified as Black; ages 18 to 45; children living with them; widowed, divorced, separated, or never married; physically and mentally able to participate in the study; able to read and understand English	Presently receiving psychiatric treatment or counseling, taking antidepressants, pregnant or had an infant child	A single open-ended question
Contributors to Depressed Mood in Black Single Mothers (Atkins, Luo, et al., 2020)	Cross-sectional	Convenience sample of 210 community-dwelling Black single mothers aged 18 to 45	Aged 18 to 45; self-identified as Black; widowed, divorced, separated, or never married; had children living with them; physically and mentally able to participate in the study; able to read and understand English	Pregnant or had an infant child, diagnosed with depression; receiving psychiatric treatment or counseling; taking antidepressants	A single open-ended question
Eliciting Willingness and Beliefs Toward Participation in Genetic Psychiatric Testing in Black/African American Mothers at Risk for Depression (Atkins, Kelly, et al., 2020)	Qualitative	19 Black/African American mothers aged 21 to 42 years	Racial/ethnic minority status or below 200% of the federal poverty, one or more minor children living with them	Current diagnosis of depression or undergoing treatment for depression, children under one year old, pregnant, over 46 years old, unable to read and comprehend English	Center for Epidemiologic Studies – Depression Scale
Depressive Symptoms and Blood Pressure in African American Women: A Secondary Analysis From the Intergenerational Impact of Genetic and Psychological Factors on Blood Pressure Study (Gao et al., 2022)	Longitudinal	250 African American women and their biological children	Biological child three to five years old, at least 21 years of age, self-identified as Black or African American, English-speaking, no psychiatric or cognitive disorder that could affect the accuracy of study data	Not given	Beck Depression Inventory
Police Discrimination and Depressive Symptoms in African American Women: The Intergenerational Impact of Genetic and Psychological Factors on Blood Pressure Study (Kalinowski et al., 2022)	Cross-sectional	Community-based sample of Black/African American women	Black or African American, 21 years old or older, fluent in English, no cognitive impairment	Any cognitive impairment, thought disorder, psychosis, mania, or other indication that they could not accurately report on their experiences	Beck Depression Inventory
Intergenerational Transmission of Depression: Examining the Roles of Racism and Trauma Among Black Mothers and Youth (Mekawi et al., 2023)	Cross-sectional	148 Black mothers and their children recruited from an urban hospital	Women aged 18 to 65 years old, could give informed consent, identified as Black or African American, had custody of a child aged 7 to 13 years	Reported an intellectual disability and/or autism spectrum disorder	Beck Depression Inventory II
Associations Between Social Determinants of Health, Perceived Discrimination, and Body Mass Index on Depression Among Young African American Mothers (Millender et al., 2021)	Longitudinal	219 adult African American mothers aged 21 to 46 years	Mothers of young children at least 21 years old, self-identified as African American or Black, English-speaking, no evidence of mental illness that could interfere with study measurements	Not given	Beck Depression Inventory
The Cumulative Influence of Perceived Discrimination, Stress, and Coping Responses on Symptoms of Depression Among Young African American Mothers (Millender et al., 2022)	Cross-sectional	250 mother-child dyads recruited from early care and education centers in Connecticut	Self-identified as Black or African American, at least 21 years old, spoke English, biological child three to five years of age, no psychiatric of cognitive diagnoses	Not given	Beck Depression Inventory
Buffers of Racial Discrimination: Links with Depression Among Rural African American Mothers (Odom & Vernon-Feagans, 2010)	Cross-sectional	Rural, low-income African American mothers of young children	All mother in the hospital who had given birth the day before	English was not their first language, lived outside the six study counties or planned to move, did not have custody of the target child	Brief Symptom Inventory 18; Center for Epidemiologic Studies – Depression Scale
Associations Between DNA Methylation Age Acceleration, Depressive Symptoms, and Cardiometabolic Traits in African American Mothers from the InterGEN Study (Perez et al., 2022)	Cross-sectional	250 dyads recruited from early care and education centers in southwest and central Connecticut	English-speaking women at least 21 years of age who self-identified as Black or African American, had a biological child 3 to 5 years old, no evidence of a psychiatric or cognitive impairment	Not given	Beck Depression Inventory
Latent Class Analysis of Depressive Symptom Phenotypes Among Black/African American Mothers (Perez et al., 2023)	Cross-sectional	Cohort of 250 mother/child dyads recruited from early care and education centers in southwest and central Connecticut	Self-identified as African American, or Black, English-speaking, at least 21 years old, had a biological child between ages 3 and 5, no psychiatric or cognitive impairment	Not given	Beck Depression Inventory
Factors Associated with Maternal Depressive Symptoms Among Low-Income, African American Smokers Enrolled in a Secondhand Smoke Reduction Programme (Shwarz et al., 2012)	Cross-sectional	Black female smokers recruited from Women and Infant Care offices, pediatric primary care clinics, and newspaper and mass transit advertisements that targeted underserved neighborhoods in Philadelphia	Female, at least 18 years of age, smoked five cigarettes per day, exposed youngest child (under 4 years old) to smoke from at least two cigarettes per day	Currently diagnosed or being treated for a DSM-IV psychiatric disorder or currently pregnant	Center for Epidemiologic Studies – Depression Scale
Modifiable Risk and Protective Factors for Depressive Symptoms in Low-Income African American Mothers (Siefert et al., 2007)	Cross-sectional	Randomly selected community-based sample of low-income African American families residing in the poorest census tracts in Detroit	At least one child under six years old, household income below 250% of the federal poverty level, biological mothers aged at least 18 years old	Other relatives and caregivers, mother aged less than 18 years old	Center for Epidemiologic Studies – Depression Scale

Concept Elements

The setting is Black mothers. It was chosen because the concept, depression, may present with different attributes in this population from the diagnostic criteria specified by the American Psychiatric Association.

Definition

Major depressive disorder is diagnosed when at least five of the symptoms listed in Table 2 are present during a two-week period (American Psychiatric Association, 2022). Either depressed mood or decreased interest in activities must be present (American Psychiatric Association, 2022).

Table 2.

Symptoms of Major Depressive Disorder

Must include one of these: Depressed mood Decreased interest in activities

Other symptoms: Weight or appetite changes Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or decreased energy Feelings of guilt or worthlessness Indecisiveness or decreased concentration Thoughts of death or suicidal ideation

These symptoms must also be a change from the individual’s baseline functioning and must not be attributable to another medical condition or a substance (American Psychiatric Association, 2022). Similarly, a diagnosis of persistent depressive disorder requires the presence of at least two of these symptoms for at least 2 years (American Psychiatric Association, 2022).

Surrogate and Related Terms

Surrogate terms express the same idea as the concept (Tofthagen & Fagerstrøm, 2010). During the search, a commonly used surrogate term was “depressive symptoms”; screening instruments for depressive symptoms may be used as a proxy for a formal diagnosis of depression, as their scoring closely correlates with clinical diagnoses (Hill & Hoggard, 2018).

Related terms, words that may be associated with the concept but have different characteristics, were hopeless, sad, discouraged, or “down in the dumps” (American Psychiatric Association, 2022; Tofthagen & Fagerstrøm, 2010).

Antecedents

Antecedents are events or phenomena that precede instances of the concept (Rodgers, 1989). The most common antecedent was perceived discrimination or racism, which was identified in eight studies (Table 3). Other antecedents were low education (n = 7), single marital status (n = 6), increased stress (n = 5), decreased social support (n = 4), older age (n = 3), low income (n = 5), higher body mass index (n = 2), trauma or negative life events (n = 2), no health insurance (n = 1), food insufficiency (n = 1), more household smokers (n = 1), poorly maintained housing (n = 1), and low optimism (n = 1). Although studies focusing on sexual trauma were excluded from this analysis, experiences with other forms of trauma, such as accidents and exposure to natural disasters, were still prevalent in this population. Perceived discrimination is particularly important because Black mothers experience both racial discrimination and gendered discrimination. Socioeconomic disparities, such as low education and income, were also prevalent in this population and were associated with depression in multiple studies.

Table 3.

Antecedents, Attributes, and Consequences of the Concept

Characteristic	References
Antecedents
Perceived discrimination/racism	(Atkins, 2015; Gao et al., 2022; Kalinowski et al., 2022; Mekawi et al., 2023; Millender et al., 2021, 2022; Odom & Vernon-Feagans, 2010; Siefert et al., 2007)
Increased stress	(Atkins, 2015; Millender et al., 2022; Odom & Vernon-Feagans, 2010; Perez et al., 2023; Shwarz et al., 2012)
Low education	(Atkins et al., 2018; Atkins, Kelly, et al., 2020; Atkins, Luo, et al., 2020; Kalinowski et al., 2022; Millender et al., 2022; Odom & Vernon-Feagans, 2010; Siefert et al., 2007)
Single marital status	(Atkins et al., 2018; Atkins, Luo, et al., 2020; Gao et al., 2022; Millender et al., 2022; Odom & Vernon-Feagans, 2010; Perez et al., 2023)
Decreased social support	(Atkins, 2017; Odom & Vernon-Feagans, 2010; Shwarz et al., 2012; Siefert et al., 2007)
Older age	(Gao et al., 2022; Kalinowski et al., 2022; Millender et al., 2021)
Low income	(Atkins et al., 2018; Atkins, Luo, et al., 2020; Gao et al., 2022; Kalinowski et al., 2022; Odom & Vernon-Feagans, 2010)
Higher body mass index	(Gao et al., 2022; Millender et al., 2021)
Trauma/negative life events	(Mekawi et al., 2023; Odom & Vernon-Feagans, 2010)
No health insurance	(Kalinowski et al., 2022)
Food insufficiency	(Siefert et al., 2007)
More household smokers	(Shwarz et al., 2012)
Poorly maintained housing	(Siefert et al., 2007)
Low optimism	(Odom & Vernon-Feagans, 2010)
Attributes
Anger/irritability	(Atkins, 2014, 2015; Atkins et al., 2018; Perez et al., 2023)
Low self-esteem	(Atkins, 2015; Perez et al., 2023)
Self-hate or self-blame	(Perez et al., 2022, 2023)
Anhedonia	(Perez et al., 2023)
Insomnia	(Perez et al., 2023)
Fatigue	(Perez et al., 2023)
Decreased libido	(Perez et al., 2023)
Consequences
Maternal negative physical health outcomes	(Atkins, 2017; Gao et al., 2022; Millender et al., 2021)
Avoidance/distancing	(Atkins, 2016; Millender et al., 2022)
Social withdrawal	(Atkins et al., 2018)
Passive coping	(Millender et al., 2022)
Child negative mental health outcomes	(Mekawi et al., 2023)
Seeking social support	(Atkins, 2016)
Problem solving	(Atkins, 2016)

Attributes

Identifying attributes makes it possible to recognize instances of the concept and differentiate the concept from other concepts (Rodgers & Knafl, 2000). Depression in Black mothers was most often associated with the attributes of anger or irritability (n = 4), low self-esteem (n = 2), and self-hate or self-blame (n = 2). Other attributes identified by this analysis included anhedonia, insomnia, fatigue, and decreased libido (Table 3). However, it is important to note that cultural influences may lead to masking of symptoms or self-silencing (Abrams et al., 2019). In addition, factors such as religiosity and marital status can improve depression in this population (Robinson et al., 2023).

Consequences

Consequences follow instances of the concept (Rodgers, 1989). The consequences identified in this analysis were maternal negative physical health outcomes (n = 3), avoidance or distancing (n = 2), social withdrawal (n = 1), passive coping (n = 1), child negative mental health outcomes (n = 1), and the positive consequences of seeking social support (n = 1) and problem solving (n =1). Negative physical health outcomes among mothers included smoking and obesity, possibly due to mothers experiencing depression being less likely to practice positive health behaviors and more likely to focus on the care of their children (Atkins, 2017; Gao et al., 2022; Millender et al., 2021). Avoidance or distancing were the most common negative coping mechanisms, followed by passive coping, or accepting the situation and keeping one’s thoughts to oneself; these coping mechanisms have been associated with more severe depression (Millender et al., 2022). Seeking social support and problem solving were positive coping mechanisms and were seen in mothers who had higher levels of optimism; these strategies may decrease depression, but they are often a last resort (Atkins, 2016; Millender et al., 2022). The consequence of negative mental health outcomes in the child was only shown in one study but has been previously documented (Mekawi et al., 2023). Figure 2 shows a conceptual diagram of depression in Black mothers, including the antecedents, attributes, and consequences.

Figure 2.

Conceptual Diagram of Depression in Black Mothers

Discussion

This concept analysis identified antecedents, attributes, and consequences of depression in Black mothers. Notably, the attributes anger or irritability, self-hate or self-blame, low self-esteem, and decreased libido, while recognized as present in many depression sufferers, are not included in the official diagnostic criteria. However, these attributes are essential for the recognition of depression in this population. Additionally, many of the antecedents are more prevalent in Black mothers than other populations. Although the consequence of maternal negative physical health outcomes is not unexpected in depressed Black mothers, the consequence of negative mental health outcomes in the child may be unknown to depressed mothers; mothers may not realize the effects their mental health can have on their children (Baker et al., 2020). Black mothers often delay seeking treatment, and this behavior could be changed if they recognized the effect their depression can have on their children (Nelson et al., 2020). Mothers may also blame themselves for their child’s mental health problems and resulting behavioral issues, which could worsen depression (Baker et al., 2020). Additionally, it may be difficult for Black mothers to engage in mental health treatment because they tend to devote their financial and emotional resources to their families, and focusing on themselves and their own mental health problems could induce feelings of guilt (Siefert et al., 2007).

Although lower income is an antecedent of depression, higher income has not been shown to be protective against depression (Atkins, Kelly, et al., 2020). Middle-class Black individuals can face the same disadvantages as lower-class individuals, such as discrimination in employment, education, housing, and the criminal justice system (Graham et al., 2020). Black mothers can also experience an accumulation of discrimination during their lives, which leads to a higher risk for depression (Millender et al., 2021). It has been proposed that perceived discrimination and stress are also antecedents to anger (Atkins, 2015). Previous research suggests that lack of control over anger and suppression of anger can lead to symptoms of depression (Atkins, 2014). Furthermore, discrimination can cause “hidden injuries” which lead to feelings of powerlessness and inadequacy and a perceived loss of dignity (Graham et al., 2020). However, the presence of social support, especially religious social support, can lead to positive coping mechanisms that may buffer the influence of discrimination on mental health (Odom & Vernon-Feagans, 2010). For many Black mothers who have no formal support system, members of the church could serve as an extended social support system (Odom & Vernon-Feagans, 2010).

It has also been proposed that stressful events and situations lead to depression, and stressful events are believed to be essential for depressive episodes (Atkins, 2015). In addition, stressful events can lower self-esteem by negatively affecting perceived self-worth (Atkins, 2015). Stressors such as low socioeconomic status and lack of social support disproportionately affect Black mothers and can predispose them to depression (Patel et al., 2023). To help minimize depression, healthcare professionals can help Black mothers manage their anger and develop more positive and effective methods to cope with the stress of perceived racism (Atkins, 2015). Healthcare professionals can also help Black mothers identify the additional stressors in their lives and assist in developing techniques for managing this stress and the associated negative emotions (Atkins, 2015).

Limitations

This analysis focused on Black mothers in the United States due to the national history of systemic racism, discrimination and oppression affecting Black individuals. The characteristics of depression identified among this population may not be relevant to mothers in another country due to cultural differences. While discrimination against individuals of African descent certainly exists internationally, countries outside the United States do not have the same legacy of enslavement of African people and later systemic racism against their descendants. In fact, studies have shown that the prevalence of mental health disorders is lower in foreign-born Black women compared to Black women born in the United States (Erving et al., 2021).

Although over 100 studies were found that addressed depression in Black women in the United States, very few focused specifically on Black mothers. In addition, many studies including a diverse sample of mothers did not report on Black mothers as a separate group and were excluded from the analysis. If these studies had examined depression in Black mothers separately, additional characteristics of this concept may have been revealed.

Implications

To develop instruments to assess depression and depressive symptoms that are culturally tailored to Black mothers, the concept must first be clarified (Tofthagen & Fagerstrøm, 2010). Healthcare providers may not be aware of the needs of Black mothers, their experiences with discrimination or trauma, or their cultural beliefs (Millender et al., 2021). This analysis shows that screening tools for Black mothers used in primary care services should incorporate such psychosocial risk factors as discrimination and trauma (Mekawi et al., 2023).

Primary care providers and nurse practitioners need to be educated on how to identify depression in this population and when to provide referrals to mental health professionals, such as psychiatrists, psychologists, or licensed clinical social workers (Mekawi et al., 2023). Obstetrician-gynecologists and certified nurse-midwives play an important role in women’s healthcare, sometimes acting as primary care providers and providing services from preventive care to psychiatric care (Raglan et al., 2020). They are uniquely positioned to implement depressive symptom screening and treatment (Raglan et al., 2020). Pediatricians are also important because after recognizing depressive symptoms in the mother and making appropriate recommendations for follow-up, these providers can assess for adverse effects in the child and offer treatment as necessary(Rafferty et al., 2019). For hospitalized individuals, acute care registered nurses are instrumental in the early recognition of depressive symptoms, as they often administer a screening test, such as the Patient Health Questionnaire, during the admission assessment (Barba et al., 2022).

If screening tests are positive for the presence of depressive symptoms, the individual should be further evaluated to determine whether treatment and follow-up are appropriate (Maurer et al., 2018). In addition, given the antecedents identified in this analysis, providers should consider implementing an assessment of social determinants of health to gain more insight into the depression risk for Black mothers. Studies of Black mothers could also be used to inform the development of an instrument specific to the attributes common in this population.

Conclusion

Depression has a high prevalence in Black mothers, largely due to the antecedents identified in this analysis, especially racism and discrimination (Atkins, Kelly, et al., 2020). However, Black mothers are less likely than their White counterparts to have health insurance or to seek mental health care, and, even when they are seen by healthcare providers, depression can go undetected and untreated (Siefert et al., 2007). Black mothers’ experiences with racism and trauma and the associated depression can negatively affect parenting and may have negative downstream effects on the child’s mental health and lead to poorer outcomes for the child (Baker et al., 2020; Mekawi et al., 2023). This analysis has shown that the underlying characteristics of depression in Black mothers may be more complex than the currently accepted definition of depression. This analysis will contribute to the nursing literature by clarifying the characteristics of depression in Black mothers and improving recognition of depression in this population.

Highlights.

• Black mothers experience depression at nine times the national rate, but they are less likely to receive treatment due to such barriers as lack of health insurance and access to treatment, lack of trust in providers, and lower health literacy.

• To understand depression in Black mothers and improve diagnosis and treatment, the attributes, antecedents, and consequences must be clarified.

• The attributes anger or irritability, self-hate or self-blame, low self-esteem, and decreased libido, while recognized as present in many depression sufferers, are not included in the official diagnostic criteria, but these attributes are essential for the recognition of depression in this population.

• Although the consequence of maternal negative physical health outcomes is not unexpected in depressed Black mothers, the consequence of negative mental health outcomes in the child may be unknown to depressed mothers; mothers may not realize the effects their mental health can have on their children.

• This analysis shows that screening tools for Black mothers used in primary care services should incorporate such psychosocial risk factors as discrimination and trauma, and healthcare providers need to be educated on how to identify depression in this population.