A Review of Treatments for Young Black Males Experiencing Depression

Abstract

The objective was to qualitatively examine the treatment effects of depression interventions on young, Black males (YBM) across treatment providers and settings via a review. Randomized controlled trials (RCTs) seeking to ameliorate depressive symptomology in Black males ages 12–29 were eligible for inclusion. After review of 627 abstracts and 212 full-text articles, 12 studies were selected. These RCTs were organized into five categories based on the intervention method. We isolated only one study that targeted YBM exclusively. Additionally, only two treatment effect sizes for YBM were available from the data. While remaining RCTs did involve Black youth, disaggregated data based on race and gender were not reported. Overall, the lack of research specific to YBM prevented any strong conclusions about the treatment effects on depression for this population. Small sample size along with poor representation of YBM were trends in the selected studies that also posed an issue. Therefore, our review produced qualitative findings but failed to isolate any true effect size for YBM being treated for depression. Until more conclusive evidence exists, alternative strategies may need to be employed in order to find appropriate interventions for depressed YBM seeking mental health treatment.

Large-scale U.S. studies have reported that up to 3% of children and 8% of adolescents suffer from depression (U.S. Department of Health and Human Services [DHHS], 2001). Epidemiological data also indicate that lifetime rates of depressive disorders almost double between the ages of 13 (8.4%) and 18 (15.4%) years (Merikangas et al., 2010). Unfortunately, half of the adolescents with severely impairing depressive disorders in the United States never receive mental health treatment for their symptoms (Merikangas et al., 2011). Lack of mental health treatment is especially true for young, Black males (YBM), ages 12–29. Data from the National Comorbidity Survey—Adolescent Supplement, for example, indicate that when compared to their White counterparts, Black adolescents are significantly less likely to receive care for depressive disorders (Costello, He, Sampson, Kessler, & Merikangas, 2014; Merikangas et al., 2011). According to the National Survey on Drug Use and Health, Black youth consistently demonstrated less likelihood to receive treatment for depression from 2004 to 2013 than their White peers (Substance Abuse and Mental Health Services Administration, 2014). Among those receiving treatment, there is a dearth of evidence about what treatments work best regarding the mitigation of depression symptoms. Limited knowledge about ideal treatment strategies, particularly given the high rates of untreated depression, in addition to a rise in suicidal behaviors, makes addressing the mental health outcomes of YBM a public health priority.

Depression Burden May Lead to Increased Suicidal Behavior Among Depressed YBM

Although prevalence of major depressive disorder is lower among Blacks than Whites, the chronicity and burden of depression are greater for Blacks (Williams, Gonzalez, Neighbors, et al., 2007). Black youth and adults report a higher prevalence of dysthymic disorder, the chronic nature of which may explain the increase in suicide among Black adolescents, especially males, from 7.1 per 100,000 in 1986 to 11.4 per 100,000 in 1997 to 12.3 per 100,000 in 2014 (Centers for Disease Control and Prevention [CDC], 2015; U.S. DHHS, 2001). One recent study further points to a disturbing trend regarding the incidence of suicide among Black adolescent boys. This study by Bridge and colleagues (2015) found that the rates of suicide among Black adolescents, particularly boys transitioning to adolescence (ages 10–11), doubled between 1993 and 2012, representing the highest rates among all young ethnic groups. According to a recent CDC (2013) report, adolescent boys, ages 12–17, are more likely than girls to die by suicide, and suicide is the third leading cause of death among all Black American youth, ages 15–24 (CDC, 2010). Depression is a precursor to suicidal behavior (Dervic, Brent, & Oquendo, 2008). As such, this warrants a closer examination of how YBM are treated for depression, particularly examining what treatments effectively work to mitigate their depressive symptoms.

Conceptualizations of Help-Seeking, Treatment Perspectives, and Depression in YBM

An examination of effective interventions and strategies to treat depression among YBM must start with this group’s help-seeking experiences and conceptualizations of depression. Extant research indicates that Black adolescents, particularly boys, see professional help as a last resort for mental health treatment, and negative social networks play a pivotal role in their help-seeking behaviors (Lindsey et al., 2006). When experiencing emotional or psychological problems, YBM discuss their problems almost exclusively with their family and receive messages consistent with not talking to “outsiders” about their mental health problems (Lindsey, Joe, & Nebbit, 2010). Peers and friends especially influence YBM’s help-seeking behaviors, for example, they fear friends would tease them about mental health treatment, which increases YBM’s reluctance to share their treatment status (Lindsey et al., 2006; Moses, 2009; Samuel, 2015). Mental health help-seeking for this group, therefore, may be more stigmatizing, and social networks are not likely to be supportive (Breland-Noble & African American Knowledge Optimized for Mindfully Healthy Adolescents [AAKOMA] Project Adult Advisory Board, 2012; Lindsey et al., 2010; Moses, 2009; Samuel, 2015). These help-seeking perspectives may, in part, explain the lower numbers of YBM with depression who actually reach treatment.

There is also a degree of self-stigma regarding the experience of depression and how YBM interpret symptoms. For example, YBM often experience depression symptoms as a sign of weakness, a sense of not being able to handle problems on their own, and perhaps even succumbing to emotional pain one should be able to handle (Lindsey et al., 2006; Samuel, 2015). Often, the symptoms of depression, for example, anxiety and excessive crying, are interpreted by YBM as weakness (Perkins, Kelly, & Lasiter, 2014). Coupled with these negative connotations of depression is the stigma associated with treatment, particularly distrust of mental health professionals. Compared with Whites, a feeling of embarrassment about seeking treatment is more severe among Blacks (Cooper-Patrick, Brown, Palenchar, Gonzales, & Ford, 1995), and Black youth often associate the use of mental health treatment for depression with feeling “shame,” especially males (Lindsey et al., 2010; Samuel, 2015). A study of Black adolescent boys found that this group also tended to question therapists’ genuineness and suspect that they would not be able to solve their problems (Lindsey et al., 2010). This mistrust of therapists, thus, can prevent YBM from seeking treatment (Lindsey, Chambers, Pohle, Beall, & Lucksted, 2013; Samuel, 2015). Additionally, mistrust might explain the lower numbers of YBM who are actually involved in clinical trials for depression. These factors ultimately contribute to low service utilization for YBM. Moreover, the severe consequences associated with untreated or undertreated depression for YBM (e.g., suicidal behaviors) warrant the need to examine efficacious treatments for this population.

Summary of Current Evidence for Effective Treatment of Adolescent Depression

The effectiveness of adolescent depression treatments have been explored in prior reviews of literature. For instance, David-Ferdon and Kaslow (2008) performed a systematic review on research-supported treatments for both child and adolescent depression and found that cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) were well-established efficacious treatments for adolescents, demonstrating positive treatment effects regardless of treatment modality (i.e., group, individual, or family). Although these treatments have been determined effective for adolescent populations as a whole, it is still unknown how well these interventions work for boys of color. Therefore, these gaps in current evidence necessitate an investigation into whether these treatments are as effective for YBM who we argue may experience greater consequences associated with untreated depression.

The Purpose of This Study

This study will examine the available RCT literature to determine treatments found to be most efficacious when targeted to YBM. The extant literature indicates that YBM are likely to have untreated or undertreated depression due to negative social network influences (Lindsey et al., 2006; Richardson, 2001), negative perceptions of services and providers (Lindsey, 2010; Richardson, 2001), or self-stigma associated with experiencing depressive symptoms (Bains, 2014). There is abundant available evidence for what works best in the treatment of adolescent depression (David-Feron & Kaslow, 2008). Despite this knowledge, what specific interventions work best for YBM and how we might target this group for treatment is still largely unclear. The purpose of this study, therefore, is to qualitatively examine the treatment effects of depression interventions on YBM across treatment providers in order to determine what may be most effective for treating this population. This review includes an assessment of the quality of previous studies and further articulation of what should be the next steps in future research on the treatment experiences of YBM with depression.

Method

On September 17, 2015, we searched EbscoHost, ProQuest, Scopus, and Web of Science for the following terms searching under the filters of abstract OR subject OR title within EbscoHost, ProQuest, and Scopus. These four databases include relevant subdatabases, that is, the ProQuest database includes Sociological Abstracts and the EbscoHost database includes MEDLINE, PsycINFO, and Social Work Abstracts. MEDLINE encompasses PubMed. The filter “topic” encompasses abstract OR subject OR title for the Web of Science database. An additional filter was the time frame of 2000–2015. We segmented the search into four larger search topics: Black, male, randomized control trial (RCT), and depression. Each search topic was compiled to be as comprehensive as possible with the aforementioned terms.

Under each of these larger research topics, the following were searched using these specific search terms:

The Black terms were searched as: “black” OR “blacks” OR “african american*” OR “african-american*.”

In searching for male terms, we extended the terms to include an array of males that could be involved in the life of an adolescent male or names that an adolescent themselves could be called to ensure a more expansive search. The comprehensiveness of this male search required five separate searches that were combined via OR, due to the large numbers of results that the male terms would yield. Therefore, the searches were (1) “boy” OR “boys” OR “brother” OR “brothers” OR “dad” OR “dads” OR (2) “father” OR “fathers” OR “grandfather*” OR “husband” OR “husbands” OR “male” OR “males” OR (3) “man” OR “men” OR “son” OR “sons” OR “stepdad*” OR “step-dad” OR “step-dads” OR (4) “stepfather*” OR “step-father” OR “step-fathers” OR “uncle” OR “uncles” OR (5) “step-brother” OR “stepbrother*” OR “step-brothers” OR “step-son” OR “stepsons” OR “stepson*.” After each of these five searches, each were connected via the OR option creating a single male search term.

Additionally, the depression terms were searched as “depres*” OR “depression” OR “manic depress*” OR “bipolar depress*” OR “bipolar disorder*.”

Similar to the male search terms, the RCT terms were searched 3 times as to not overload the system and were separated to encompass the varied terms used for RCT and later connected via an OR search. The first and second RCT term searches were separately searched as (1) “randomi* control* trial*” OR “randomi* clinical trial*” OR “randomi* trial*” and (2) “rct.” The third RCT searches had to be individualized to the respective databases. Within EbscoHost, the RCT term was “randomi* W10 trial*.” Within ProQuest, the RCT term was “randomi* PRE/10 trial*.” Within Scopus, the RCT term was “randomi* PRE/10 trial*.” Within Web of Science, the RCT term was “randomi* NEAR/10 trial*.” Accordingly, these three separate terms for RCT were combined via the OR option creating a single RCT search term. Upon creating these four larger search terms, the results were combined using the AND option: Black terms AND RCT terms AND male terms AND depression terms.

Only English-language publications and articles from scientific journals populated from our search results. The search results were also limited to studies with populations between the ages of 12 and 29. Within the ProQuest and Scopus databases, there were not specific age limiters available for these inclusion criteria. Therefore, all abstracts were examined for age information in order to limit the results that were used in the final analysis. Articles with abstracts that definitively indicated the desired age ranges were designated for full review as well as articles with abstracts that did not indicate specific age information. Articles with abstracts that indicated age ranges outside of 12–29 were discarded. Two independent reviewers examined the remaining articles to ensure inclusion criteria were met.

We received a total of 627 articles from the initial searches. Subsequently, two coauthors independently reviewed the abstracts of all 627 articles to ensure that inclusion criteria were met. The inclusion criteria were based on Black males between the ages of 12 and 29, who participated in RCTs targeting depression. If the article met the inclusion criteria, or was deemed inconclusive based on the article abstract, it remained in the count. The two coauthors made these determinations, comparing their notes after reviewing each abstract. Upon the completion of this initial review of abstracts, 212 articles remained to be independently reviewed in order to determine whether these articles entirely met the qualifications for inclusion. This final, more rigorous abstract review yielded 12 articles that met study inclusion criteria (see Figure 1).

Figure 1.

Flow diagram of depression studies: Exclusion and inclusion.

Results

See Table 1 for summary of the study results. The total sample size for all 12 studies included in this review was 2,586 clients. A total of 1,591 (61.5%) clients could be confirmed as male, since one study did not specify by gender. A total of 821 (32%) clients could be confirmed as Black. The total sample age range was 8–21 years, in which the mean age was 17.98 (one study did not report the mean age) and the total standard deviation was 1.63 (three studies did not report standard deviation).

Table 1.

Randomized Depression Interventions Involving Young, Black Males.

Author	Intervention	Demographics	Outcomes	Did It Work?	Did It Work for Black Males?
Youth-centered behavioral treatment (four articles)
Bittman, Dickson, and Coddington (2009)	HealthRHYTHMS	12- to 18-year-old adolescents N = 30 females N = 22 males Includes African American	Depression reduction	Yes; 6.1% reduction in depression total versus a depression within the conduction group 0.004 statistical significance	Unknown; results are not reported based on race
Breland-Noble and AAKOMA Project Adult Advisory Board (2012)	AAKOMA Family Leadership Over Adolescent depression project	11- to 17-year-old African American adolescents N = 5 males N = 11 females	Depression treatment enrollment readiness	Yes; 100% effective in encouraging Black adolescents into depression treatment N = 5 versus 75% of delayed control group entered into depression treatment	Unknown; Black male specifics not identified
Gunlicks-Stoessel, Mufson, Jekal, and Turner (2010)	Interpersonal psychotherapy for depressed adolescents	12- to 18-year-old adolescents (14.3% Black) N = 53 females (84.1%) N = 10 males (15.9%)	Depressive symptom reduction	Yes; for adolescents with high levels of conflict with mothers showed greater acceleration 0.35 effect size on baseline depression	Unknown; Black male specifics not identified
McMullen, O’Callaghan, Shannon, Black, and Eakin (2013)	TF-CBT	13- to 17-year-old former child soldiers (n = 39) and war-affected boys (n = 11) *Republic of the Congo	Depressive symptom reduction	Yes; 31.1% reduction in depression and anxiety versus 8.9% reduction in control group 0.567 effect size on depression and anxiety	Yes; 100% of the population were Black males
Youth-centered pharmacological/behavior treatment (one article)
March and Vitiello (2009)	Treatment for adolescents with depression study	Specific demographics unreported in article, but notes minority representation Known as a universal intervention for all adolescents despite race	Depressive symptom reduction	Yes; combination of CBT and fluoxetine works best with reducing depressive symptomology	Unknown; there was no indication of how many of the males were Black
Family-centered behavior treatment (four articles)
Brody et al. (2012)	Strong African American Families–Teen	502 Black families	Depressive symptom reduction	Yes; adolescents received a 12% reduction in depressive symptoms	Yes; 4% more effective for Black males than females
Compas et al. (2010)	Family group cognitive behavioral	120 families with six (5%) Black	Depressive symptom reduction	Yes; depressive symptoms mediated through coping skills	Unknown; there was no indication of how many of the males were Black
Diamond, Reis, Diamond, Siqueland, and Isaacs (2002)	ABFT	32 adolescents; 22% male; 69% Black adolescents	Depressive symptom reduction	Yes; 81% of patients in ABFT no longer major depressive disorder versus only 47% of those on the waitlist	Unknown; there was no indication of how many of the males were Black
Diamond et al. (2010)	ABFT	11 males in the trial; 70% Black adolescents	Depressive symptom reduction	Yes; 0.97 effect size	Unknown; there was no indication of how many of the males were Black
Quality of depression treatment in primary care (two articles)
Asarnow et al. (2009)	Quality improvement trial	13- to 21-year-olds; 13% of total are Black adolescents; 22% of total are Black males	Depressive symptom reduction	Yes; 10% fewer of the treatment group had severe depression symptoms than the control group; only through 6 months There were no long-term effects within the treatment	Unknown; treatment effect were not isolated
Ngo et al. (2009)	Youth partners in care	13- to 21-year-old adolescents 18% of the 325 adolescents were Black	Depression reduction	Yes; between 12% and 13% reduction in depression intervention for Black adolescents from usual care	Unknown; Black adolescents showed reduction, but Black males not specifically were not reported
Home environment treatment (one article)
Leventhal and Brooks-Gunn (2003)	Moving to Opportunity for Fair Housing Demonstration	11- to 15-year-old adolescents 49.9% of the families are African American 6.8% of male adolescents	Depressive reduction	Yes; reduction in depressive symptoms	Unknown; males within the experimental groups reporting significantly less likely to suffer from depressive symptoms. Black male count is unknown.

Note. TF-CBT = trauma-focused cognitive behavior therapy; ABFT = attachment-based family therapy.

The 12 articles fell into five distinct categories of treatment: Youth-centered behavior treatment (YBT; four articles), youth-centered pharmacological/behavior treatment (YPBT; one article), family-centered behavior treatment (FCBT; four articles), quality of depression treatment in primary care (QDTPC; two articles), and home environment treatment (one article). We defined and organized these treatment categories based on the study results and will further describe these categories in greater detail below.

During this process, we attempted to identify the effect size of depression treatments for YBM in each study. However, we were only able to report on two effect sizes specific to Black males with the available data. Although many remaining articles did not provide outcome data specific to ethnicity or gender, these studies still met inclusion criteria, and therefore, the results for YBM were interpreted as the results of the group. It became apparent after review that YBM were indeed part of the intervention group in each study and, therefore, were affected by the intervention that the study sought to provide. In these cases, the results of the study were presented to highlight the inclusion of YBM in the RCT, but it should be noted that other gender and ethnic groups received the intervention and related effects as well. The next subsections discuss the available evidence pertaining to effective treatments that ameliorate depressive symptomatology among YBM as per the aforementioned categories.

Youth-Centered Behavior Treatment (YBT)

YBT is treatment centered solely on the individual youth. This type of treatment focused on reducing the youth’s behavioral outcomes only related to depressive symptomatology. These interventions may be delivered in multiple environments and do not include pharmacological components nor require environmental changes. Below we report on four studies that adhere to this definition of YBT.

First, Bittman, Dickson, and Coddington (2009) conducted an RCT intervention on 12- to 18-year-olds with mental health disorders including depression. The sample size (n = 52) included 30 females and 22 males that identified as Black, Asian, Caucasian, or Puerto Rican. The specific sample size for Black participants was not indicated in this study. The study used HealthRHYTHMS, a musical instrument intervention which was provided over six weekly sessions, along with monitoring shifts in mental health symptomology. Control group participants continued treatment as usual. The study utilized the Reynolds Adolescent Depression Scale (RADS), Second Edition index to assess depression symptomatology. After the intervention, the experimental group showed a 6.1% decrease in depressive symptoms, while the control group showed a 2% increase in depressive symptoms on the same scale. Postintervention results from the RADS index show that youth, including YBM, made additional improvements in reduced anhedonia, negative affect, and negative self-evaluation beyond improvements in overall depression after receiving the musical instrument intervention. Comparison of pretest-post-test results from the experimental group to the control groups suggests that anhedonia/negative affect was the only area of maintained improvement that relates to depression for YBM and their counterparts.

From a different perspective, Breland-Noble and AAKOMA Project Adult Advisory Board (2012) used motivational interviewing in an RCT intervention for Black adolescents between the ages of 11 and 17. Both the Children’s Depression Rating Scale–Revised (CDRS-R) and the University Rhode Island Change Assessment (URICA) were administered and scored to determine whether referred youth met inclusion criteria. The focus of this study was comparing rates of entry into depression treatment between an intervention group (those receiving both motivational interviewing and a depression treatment) and a delayed control group, who were solely offered free clinical services without motivational interviewing. The main outcome variable was attendance at initial treatment sessions. The sample size (n = 16) included 11 females and 5 males, all of whom identified as Black American. While 74% of the Black youth recruited for this study actually enrolled, 94% of the screened adolescents identified as being in the precontemplation readiness stage according to the URICA index. This study reports that 100% of the adolescents who completed the motivational interviewing component remained enrolled and attended their first session for depression treatment. But, only five of the eight youth who engaged in the motivational interviewing component completed the engagement protocol. Additionally, six of the eight youth in the delayed control group attended the first treatment session. No data on depression treatment completion for either group are presented in the article. This study concludes that although Black adolescents, including males, assigned to the motivational interviewing intervention had higher attrition rates than the delayed control group, many of these adolescents still initiated depression treatment and reported high rates of consumer satisfaction. Breland-Noble and AAKOMA Project Adult Advisory Board (2012) suggest that the impact of motivational interviewing is more effective, if delivered more immediately.

The third article by Gunlicks-Stoessel, Mufson, Jekal, and Turner (2010) is an RCT study that compares the impact of interpersonal psychotherapy for depressed adolescents ages 12–18 to treatment as usual in school-based clinics. The sample (n = 63) was composed of 15.9% adolescent males and 14.3% Black American youth. Assessments with the Schedule for Affective Disorders and Schizophrenia for School–Age Children (K-SADS), Hamilton Rating Scale for Depression (HRSD), Conflict Behavior Questionnaire–20, and Social Adjustment Scale–Self-Report were made at baseline and 4, 8, or 12 weeks or at early termination. Results showed that interpersonal psychotherapy for depressed adolescents, including YBM, was beneficial for those with high levels of conflict with their mothers and social dysfunction with friends. Statistical analysis points to adolescents’ perceived social dysfunction with friends as a moderating factor for reduction in depression symptoms. Contrastingly, adolescents’ perceived social dysfunction in dating proved insignificant in their depression symptom trajectories. Gunlicks-Stoessel et al. (2010) also reported an insignificant correlation between youths’ perceived conflict with mothers and a reduction in depressive symptoms, although interpersonal psychotherapy was proven beneficial in other domains of the adolescents’ lives.

While the three previous studies were based in the United States, McMullen, O’Callaghan, Shannon, Black, and Eakin (2013) conducted an RCT intervention in the Democratic Republic of the Congo. This study instituted a treatment plan, which delivered 15 sessions of trauma-focused cognitive behavioral therapy (TF-CBT), for 13- to 17-year-old males (n = 50), who were child soldiers or were affected by war. The participants were assessed at baseline, post-intervention, and at 3 months after the intervention with the UCLA–PTSD reaction index and the African Youth Psychosocial Assessment (AYPA). Treatment group participants, all Black adolescent males, showed a 31.1% reduction in depression and anxiety, whereas the control group reported an 8.9% reduction in symptoms. The overall effect size was 0.567 in minimizing depression and anxiety and this treatment effect was maintained for at least 3 months post-intervention.

Youth-Centered Pharmacological/Behavioral Treatment (YPBT)

Our next treatment category is described as youth pharmacological and behavioral treatments (YPBT). This approach makes an effort to reduce depressive symptomatology through both pharmacological interventions (e.g., antidepressant medication) and interventions directed toward changes in behavior centered on the adolescents themselves. Only one study fit into this treatment category.

March and Vitiello (2009) analyzed an RCT that assessed the comparative effectiveness of fluoxetine, CBT, and combined fluoxetine and CBT within the Treatment for Adolescents With Depression Study (TADS). Assessments were performed at 12, 36, and 52 weeks, but the index or scaling methods were not disclosed in this article. Sample size and characterization are also not reported.

Instead, the authors claim that this trial holds “excellent minority representation” (March & Vitiello, 2009, p. 1119), including that of Black adolescent males. Also asserted is that in most CBT or medication studies, positive change occurs 60% of the time, meaning that the addition of pharmacological treatment significantly improved outcomes versus therapy on its own for the majority of participants. March and Vitiello (2009) found that the TADS treatment for youth, which utilized combination therapy, leads to maximum benefit with a 71% response rate. Analysis from the TADS study suggests that even when combination therapy is discontinued, this intervention produces the sustained benefit of long-term reduction in depressive symptoms for youth. In conclusion, the TADS study claimed that 6–9 months of combined fluoxetine and CBT should be the model treatment for depression in youth, with no distinction of the results made for YBM.

Family-Centered Behavior Treatment (FCBT)

The next sets of interventions are identified as FCBT, which is centered on both the youth and their family. These treatments focus on reducing behavioral outcomes related to depressive symptomatology for the youth by including their families in treatment. These interventions may be delivered in multiple environments and may include pharmacological components and environmental changes. Below we report on four treatments that adhere to this definition.

Brody et al. (2012) conducted an RCT intervention using the Strong African American Families–Teen (SAAF-T) model. This community-based program, set in a rural area, targeted 16-year-old Black adolescents within 502 families and engaged them and their families in five sessions for a total of 15 hours in treatment. Families were assigned to either the treatment group (n = 252) or an attention control condition (n = 250). Results point to effectiveness for rural Black adolescents in limited prevention of depressive symptoms, substance use problems, and conduct problems compared to the control group at 22-month follow-up. The adolescents experienced a 12% reduction in depressive symptoms based on pre- and post-intervention Center for Epidemiologic Studies Depression (CES-D) scores. The CES-D scores from the sample demonstrated that 31% of the Black adolescents met criteria for moderate level (CES-D > 16) of depressive symptoms. Brody et al. (2012) noted that the SAAF-T intervention would be even more effective in reducing depressive symptoms in adolescents, including YBM, by adding components that support problem-focused coping and attributional styles that reduce self-blame and guilt. This intervention was also 4 % more effective for males than for females.

The second study providing FCBT was conducted by Compas et al. (2010) and compared a 12-week family group cognitive behavioral (FGCB) intervention to an 8-week written information intervention. The focus of the study was to examine the treatment effect on adolescents’ depressive symptoms, internalizing/externalizing behaviors, and parents’ depressive symptoms, parenting, and coping. Of the sample size (n = 111), only six (5%) of the families were identified as Black. Treatment was shown to prevent mental health problems for children of depressed parents with effects lasting up to 12 months. Compas et al. (2010) explained that adolescents experienced growth in their use of coping skills from the FGCB intervention, which had a mediating effect on depressive symptoms. Overall, the FGCB intervention was found to have a desired effect (reduction of 32% at 6 months to 49% at 12 months) on adolescent self-report of depressive symptoms (CES-D scores), more so than the written information comparison intervention (reduction of 24.5% at 6 months to 27.6% at 12 months) provided by mail.

In the next article, Diamond, Reis, Diamond, Siqueland, and Isaacs (2002) compared a 12-week attachment-based family therapy (ABFT) intervention to a minimal contact wait-list group. There were 32 adolescents who met criteria for DSM-III-R major depressive disorder in a sample that was 22% male and 69% Black. This study reported that 81% of patients in ABFT ceased to meet criteria for major depressive disorder, while 47% of patients did the same from the wait-list group. The intervention group experienced a reduction in depressive symptoms in addition to reduction in anxious symptoms and family conflict. Only 15 treated cases were assessed at 6-month follow-up and 13 of these patients (87%) continued to not meet criteria for major depressive disorder. Out of the adolescents treated with ABFT, including YBM, 56% no longer met the clinical diagnosis for depression based on their Beck Depression Inventory (BDI) scores at 6 weeks, compared to only 19% of adolescents in the wait-list condition. Diamond et al. (2002) reported that clinical improvement—demonstrated with a BDI score of equal to or less than 9—was reached in 56% of youth by mid-treatment, while only an additional 6% of youth reached this level by post-treatment. The authors suggest that the treatment may have the greatest impact within the first 6 weeks for both Black adolescent males and their peers.

Lastly, in a follow-up study, Diamond et al. (2010) compared ABFT to enhanced usual care outcomes for adolescent ages 12–17. Measurements were taken at baseline and 6, 12, and 24 weeks utilizing scales such as the Suicidal Ideation Questionnaire–Junior (SIQ-JR) and Scale for Suicidal Ideation (SSI) to measure suicidal ideation along with depressive symptoms in youth using the BDI-II Scale. Of the 66 participants in the sample, 11 were males and 70% of participants identified as Black. ABFT was significant in reducing depressive symptoms during treatment and follow-up with an effect size of 0.97 for the treatment group, which included YBM. In this case, Diamond et al. (2010) found that clinically meaningful change in depressive symptoms was significant at all points in time, for example, mid-treatment and post-treatment, for adolescent youth in this sample.

Quality of Depression Treatment in Primary Care (QDTPC)

The next category of treatment is QDTPC, which focused on reducing youth behavioral outcomes related to depressive symptomatology through adjusting the quality of service provision in a given location (e.g., training the workforce to deliver quality depression treatment in a primary care facility). Below we report on three treatments that were identified in this category.

Asarnow et al. (2009) conducted a multisite RCT for adolescents’ ages 13–21 centered on quality improvement for those experiencing depressive symptoms within primary care settings. The quality improvement intervention focused on a number of mental health specialty enhancements including experts to lead the adaptation and implementation of the intervention on site, clinical care managers linking individuals to specialty mental health services, enhanced mental health training for care managers, and patient/provider choice of treatment modality (Asarnow et al., 2009). Participants were randomly assigned to 6-month quality improvement intervention group (n = 211) or to an enhanced treatment-as-usual group (n = 207), across six total sites. Black adolescents made up 13% of the sample population and 22% of the population were reported to be males. Using the CES-D Scale index, 6 months into the quality improvement intervention, only 30.59% of the intervention group scored as having severe depression as opposed to 40.23% of the treatment-as-usual group. The data from this RCT point to first recovery being reached about 1 month earlier for adolescents, including YBM, in the experimental group versus the treatment-as-usual group.

Another service environment quality improvement analysis was conducted by Ngo et al. (2009) and utilized the same RCT intervention as Asarnow et al. (2009) called the “Youth Partners in Care” study. Ngo et al. (2009) sought to track ethnic differences in outcomes. As previously described, this treatment study included combined behavioral and pharmacological treatment with provider-based enrichment (e.g., additional training and education) and a control group that received usual care. This analysis included 325 adolescents between the ages of 13 and 21, of which 59 identified as Black, 224 identified as Latino, and 42 identified as White. Ngo et al. (2009) found that the total number of psychotherapy visits significantly increased for Black adolescents, including males, as an effect of the quality improvement intervention. During the 6 month follow-up period, the average CES-D score for Black youth in the experimental group no longer indicated severe depression, while the average CES-D score remained elevated (CES-D > 24) in the treatment-as-usual control group.

Home Environment Treatment

One study provided treatment targeting the actual home environment of Black male adolescents as a means of ameliorating depressive symptomology, which we refer to as home environment treatment. Leventhal and Brooks-Gunn (2003) conducted an RCT intervention within public housing under the Moving to Opportunity for Fair Housing Demonstration (MTO). This study assessed an experimental group of 550 families in public housing who moved from high-poverty neighborhoods into private housing in non-poor or near-poor neighborhoods and a control group of families who remained in public housing. Black American families represented 49.9% of the total family population and the youth were evenly distributed by male and female gender. Within the larger study, 512 children aged 8–18 years old were assessed for psychosocial well-being. These children provided self-reports of their mental health symptoms over a 6-month period with the behavior problem index. Results from the MTO trial suggest that boys in the experimental group were significantly less likely to suffer from anxiety and depressive problems than the control group and that there was a 39% reduction in problem areas due to the intervention. Unfortunately, for the focus of this review, the most pronounced intervention effects were for boys and children ages 8–13 while no significant findings for youth ages 14–18 were produced.

Discussion

This review sought to identify efficacious treatments to relieve depression symptoms among YBM. Attention given to the experiences of depression among YBM are warranted, particularly given the rising rates of suicide for this population (Bridge et al., 2015). While instructive regarding possible interventions and strategies to target depression symptom reduction for this population, there are several qualifiers we acknowledge concerning our findings. First, the numbers of YBM participating in the RCTs were generally small. Second, in most cases, we could not disaggregate findings specific to YBM among other ethnically diverse youth who were included in the samples.

Overall, these studies demonstrated reduction in depressive symptoms in samples that included YBM. Improvements from 6% to 31% were observed for depression symptom reduction (Asarnow et al., 2009; Bittman, Dickson, & Coddington, 2009; Brody et al., 2012; McMullen, O’Callaghan, Shannon, Black, & Eakin, 2013; Ngo et al., 2009). The combined treatments approaches appear to have the most potential benefit; a 70% reduction in symptoms across studies, and these effects were sustained. Interventions ranging from CBT-focused treatments (Compas et al., 2010; March & Vitiello, 2009) to interpersonal psychotherapy (Gunlicks-Stoessel, Mufson, Jekal, & Turner, 2010) to family-focused treatments (Brody et al., 2012; Compas et al., 2010; Diamond, Reis, Diamond, Siqueland, & Isaacs, 2002; Diamond et al., 2010; Leventhal & Brooks-Gunn, 2003) all appeared to influence the reduction of depression symptoms. It also appeared that holistic treatment approaches that target YBM as individuals in diverse approaches, for example, behavioral and pharmacological treatment (Asarnow et al., 2009; March & Vitiello, 2009; Ngo et al., 2009) as well as those that aim at changes in key personnel, for example, family (Brody et al., 2012; Compas et al., 2010; Diamond et al., 2002, 2010) and environments, for example, school (Bittman et al., 2009), primary care (Asarnow et al., 2009), or residential neighborhood (Leventhal & Brooks-Gunn, 2003) in their respective ecology are worth further evaluation.

Of the 12 articles, only 1 reported on the treatment effect size for YBM. McMullen et al. (2013) reported a 0.567 effect size in depression symptom reduction among YBM residing in the Democratic Republic of the Congo. For that particular study, it appears that TF-CBT has evidence of reducing trauma symptoms related to PTSD among adolescents, but the evidence was less clear about depression (de Arellano et al., 2014). While the findings on the impact of TF-CBT on depression symptoms in the McMullen et al. study are promising, we should interpret their findings with caution given the small sample size (n = 50). The majority of the sample in the McMullen et al. study was child soldiers (78%), while the remaining children were affected by war (22%). Future research may need to isolate samples of adolescent soldiers and war-affected adolescents, respectively, for a more refined understanding of the impact of these experiences. Also, consideration must be given to the differences that may impact this sample due to the geographic location and cultural distinctions of the participants in the Democratic Republic of the Congo.

Additionally, we cannot conclusively say that one treatment category should be preferred over the others for YBM. Effectiveness in each individual treatment category (YBT, YPBT, FCBT, QDTPC, and home environment treatment) cannot be drawn upon since all but one trial presented aggregated data based on both ethnicity and gender specifications. This reflects the lack of specific depression treatment effects relative to YBM, and we know from extant research that the rates of suicide continue to increase for this group (Bridge et al., 2015). However, there is evidence that effectiveness is increased utilizing combined treatment approaches. Successful combined treatment strategies for YBM could be explored in future trials.

Scales used to assess depression symptoms varied across the studies. The most consistently used scale was the CES-D, which four of the RCTs utilized as a measure of elevated depression symptomatology. The second most popular scale was the BDI, which was used in two RCTs. No other scale was reported on in more than one article. The remaining scales included RADS, CDRS-R, K-SADS, HRSD, ULCA-PTSD, AYPA, BPI, SIQ-JR, and SSI, which were all utilized in only one of the selected studies. Additionally, one trial failed to report on the measure used to identify depression. This variety in depression scales gives wide interpretation of depression outcomes and also may bring in to question the psychometric appropriateness of these scales across ethnic groups. For example, a study by Lu, Lindsey, and Nebbitt (in press) suggests that the CES-D Scale may have unique factor structure (i.e., the two-factor vs. four-factor structure commonly reported in the literature) for Black adolescents relative to its factor structure in the general population. Other studies reflect the more nuanced ways in which Black youth, particularly males, manifest depression symptoms (Perkins et al., 2014). This may all suggest that one factor leading to the underrepresentation of YBM in RCTs is how we identify and assess their mental health symptoms.

Importantly, our findings reflect the basis for a critique of the literature on depression treatment for YBM. For example, it is important to start to explore what might be done to improve the connection of YBM to treatment, especially given most large-scale studies reflect that relative to their White counterparts, Black adolescents do not receive treatment for depression (Merinkangas et al., 2011). Only one trial, Breland-Noble and AAKOMA Project Adult Advisory Board (2012), focused on the engagement of Black youth in treatment, in addition to addressing their depression symptoms. Given the small samples of Black youth across the RCTs, greater attention needs to be paid to how best to address this demographic’s treatment engagement challenge and overall access to care.

Limitations

By searching RCTs based on the interaction between age, ethnicity, gender, and depression, our investigation drew together few conclusive results, simply because such intersections reduce sample size and related effects. Even the number of Black males represented within these trials was proportionately small. A previous systematic review also acknowledges “statistical interaction terms are often associated with small effect sizes and are therefore difficult to detect and replicate” (Scott, Wallander, & Cameron, 2015, p. 348). Therefore, we cannot reach any definitive conclusions without access to a larger sample size. Our review is a qualitative investigation into the number of YBM involved in 12 studies providing depression interventions. Additionally, our study cannot determine the specific strategies or “microinterventions” (i.e., interventions within the intervention) that mitigate depression symptoms. These strategies might point to key mechanisms or mediators of change that warrant special targeting when treating YBM for depression.

Implications for Future Research

After carefully reviewing the relevant literature derived from several databases, it became clear that RCTs specifically addressing depression in YBM are limited. Instead, it seems RCTs targeting depression in youth are designed to study the population as a whole and rarely provide ethnic-specific data. More often the data are disaggregated into gender outcomes. These research trends create a challenge when attempting to isolate treatment effects in certain ethnic groups including Black males. Perhaps exploring depression interventions for gender outcomes between Black males and females in addition to focusing more large-scale studies on specific within-group differences, for example, only Black male adolescent participants, could prove to be promising areas of research regarding depression treatment among Black youth. Certainly, we recommend that future studies attempting to target the effects of depression interventions for YBM employ alternative strategies in order to produce more specific findings that could eventually inform both practice and policy areas alike.