Depression shows up differently in Black women—and that could lead to underdiagnosis. Here are the major signs

In a recent newsletter, Los Angeles-based journalist Monique Judge opened up about her experience with dysthymia, also known as “persistent depressive disorder.”

“The easiest way to explain this to people is to say that even when I am absolutely happy and loving life, depression is following me around like a stalker—a dark bully lurking in the shadows, waiting for an opportunity to pounce on me and take me down,” Judge writes. “Sometimes there isn’t a definitive reason for it. It will just sweep over me and everything changes. I can’t focus; I can’t get things done; my mood changes; I don’t want to be around people; and sometimes, I just sit around and cry a lot.”

Her experience mirrors that of many Black women who are either functioning or over-functioning through depressive states. In a recent study published in Nursing Research, researchers found that depression may look different in Black women, citing more reported instances of sleep disturbances, self-criticism and irritability, which can result in underdiagnosis and undertreatment.

“I’ve seen Black women feeling guilty, shameful, and confused by their experiences of depression or their symptoms of depression,” says Michelle Goodloe, an Atlanta-based licensed clinical social worker and founder of GMichelle Wellness. I’ve also seen Black women feeling frustrated or in denial of the depressive symptoms – there is a stigma of “I must be weak” or “I must be bad” for experiencing depression. That narrative is far from the truth.

Researchers analyzed 227 Black women who had been screened for depression as part of a study that “sought to understand the genetic, psychological and environmental factors that contribute to high blood pressure,” according to a press release about the study.

The women with greater depressive symptoms were more likely to report physical symptoms, such as fatigue, insomnia and decreased libido, as well as self-critical symptoms, such as self-hate and self-blame, compared to more common depression symptoms like feelings of hopelessness. Black women in the study also reported an ability to experience pleasure and irritability.

It’s a feeling Judge described in her newsletter: “My default when these depressive episodes happen is to work very hard to fight my way out of it. Who has time to be depressed? A depressed mind can’t write, and if I can’t write, I can’t eat or make money. Get up girl. Pull yourself together.”

That approach to “push through” is not surprising to Davia Roberts, a Washington, D.C.-based licensed professional counselor and executive director of CarrierBradley Agency.

“When we consider the ongoing forms of oppression that Black people face, it's not a surprise when a client discloses depressive symptoms,” she explains. “Black women constantly navigate racism, systemic and interpersonal, in addition to sexism and a special blend of misogynoir (a term coined by Moya Bailey). These barriers, in addition to the ongoing challenges of daily life, can contribute to depressive episodes.”

Implicit bias and depression

While depression and how it manifests differs from person to person, Roberts believes that Black women’s symptoms are often misunderstood due to the stereotypes associated with this group.

“Rather than recognize irritability as a common symptom of depression, a clinician's bias can perceive that symptom as rudeness or hostility,” she says. “When you have centuries of anti-Black stereotypes that label Black women as mean, aggressive, and self-sufficient; it can lead to misdiagnosis. The same can be said for the Strong Black Woman stereotype.”

As an example, Roberts points to a client’s chronic need to “be better and do better.” She maintains it is the clinician’s role to investigate the source of this thinking to determine a potential diagnosis.

“Is this person motivated or does this person believe they're no good unless they're perfect at everything? Is this person challenging themselves or are they trying to prove their worth?” she asks. “If you only see Black women as strong, it's easy to perceive these comments as mentally 'tough and motivated.' While Black women embody those characteristics, clinicians need to make space to explore the nuance.”

Essentially Roberts believes it’s not that depression necessarily shows up differently in Black women compared to other groups, it’s that clinicians’ unchecked racial biases can impact proper diagnosis.

“Our symptoms aren't anomalies,” she says. “However, if your interactions with Black women are ingested through a lens of 'Strong Black Women' or 'Angry Black Women' archetypes, Black women will always be at a disservice.”

Navigating depression as a Black woman

Although there’s been a rise in Black women adopting the #SoftLife movement and giving themselves permission to explore leisure, rest and a more peaceful lifestyle, Roberts would like to see an ongoing practice of vulnerability.

“It's one thing to shed the hustle mentality and ease into more restful lifestyles. However, there's a level of healing and freedom that transpires when we allow ourselves to be vulnerable, seen, and supported by trusted community,” she says.

“I've found that many Black women struggle to be vulnerable with others, even trusted friends or partners. They find it easy to help others, but express concerns about being a burden or inconvenience. When you continually serve the needs of others while de-prioritizing your needs, there's a chance that your depressive symptoms may increase in intensity or become more frequent.”

Rather than trying to ride out depressive symptoms, Roberts suggests proactively seeking support, whether that’s talking with a friend, joining a support group or giving psychotherapy a try.

“With counseling, Black women can be met with care and tools to focus exclusively on their needs without apology,” she says. “That one hour a week can be a game changer for women who are accustomed to single-handedly facing every challenge.”

Most importantly, Roberts reminds Black women that it’s essential to extend themselves grace.

“Even with the right therapist, support system and meds, you may still experience depressive episodes. This isn't a sign that you're doing anything wrong. Life is hard,” she reassures. “Our healing is not determined by our ability to numb every uncomfortable emotion. Instead, it's the ability to sit with our emotions and move through them without getting lost in them.”

This story was originally featured on Fortune.com

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