Evaluating Depressive Symptoms Among Low-Socioeconomic-Status African American Women Aged 40 to 75 Years With Uncontrolled Hypertension: A Secondary Analysis of a Randomized Clinical Trial

Key Points

Question  What is the prevalence of depressive symptoms among African American women with uncontrolled hypertension who use a federally qualified health center as their medical home?

Findings  In this secondary analysis of a randomized clinical trial, 57.0% of the participants scored 10 or greater on the 10-item Center for Epidemiological Studies Depression Scale Revised score. Women with less than a high school diploma and women who smoked with chronic health conditions had a higher prevalence of depressive symptoms.

Meaning  Health care clinicians serving low-income, midlife African American women with hypertension should screen for depressive symptoms and provide and/or refer patients to adequate mental health services.

Importance  Depression is one of the leading causes of disability in the United States. African American women of low socioeconomic status with uncontrolled hypertension are at risk of having severe depressive symptoms, yet there is limited research about the mental health of this vulnerable population. Data from the Prime Time Sister Circles randomized clinical trial (PTSC-RCT) study can shed light on the prevalence of depressive symptoms among low-socioeconomic-status older African American women with hypertension.

Objective  To determine the prevalence of depressive symptoms among low-socioeconomic-status African American women aged 40 to 75 years with uncontrolled hypertension who receive their care from a federally qualified health center (FQHC) and to identify risk factors associated with depressive symptoms.

Design, Setting, and Participants  Cross-sectional analysis of data from the PTSC-RCT of depressive symptomology, measured using an adapted version of the 10-item Center for Epidemiological Studies Depression Scale Revised (CES-D-10). Descriptive statistics were used to characterize the study population. We used logistic regression models to investigate the factors associated with participants with or without symptoms of depression. We used baseline data from the PTSC-RCT study, including 316 African American English-speaking women between ages 40 and 75 years with hypertension (systolic blood pressure ≥140 mm Hg or diastolic ≥90 mm Hg), who received their primary care at a FQHC in Washington, DC, in 2017 and 2018 and were flagged by the FQHC as uncontrolled.

Main Outcomes and Measures  We used the CES-D-10 from the Center for Epidemiologic Studies Depression Scale to measure presence of depressive symptoms.

Results  A total of 57.0% of the women in the study (180 of 316) scored greater than or equal to 10 on the CES-D-10. Depressive symptoms had a negative association with a postsecondary education (adjusted odds ratio [aOR], 0.492; 95% CI, 0.249-0.968) and a positive association with the number of chronic conditions (aOR, 1.235; 95% CI, 1.046-1.460) and smoking (aOR, 1.731; 95% CI, 1.039-2.881).

Conclusions and Relevance  In this study of low-income African American women with uncontrolled hypertension, more than half had symptoms of depression that was associated with less than high-school education, chronic conditions, and smoking. Low-income African American women with uncontrolled hypertension should be screened and adequately treated for depressive symptoms.

Trial Registration  ClinicalTrials.gov Identifier: NCT04371614

According to national data reported in 2017, 17.3 million adults in the United States experienced 1 major depressive episode.¹ Experiences with depressive symptoms are associated with aging, sex, socioeconomic status (SES), and preexisting medical conditions.^2-10 When stratified by race/ethnicity alone, the prevalence of depression among African American individuals is comparable with White individuals. However, older African American individuals with multiple medical problems and decreased activities of daily living are at greater risk of depression than their White counterparts.^3,4 Older African American individuals are less likely to be knowledgeable of the signs and symptoms of depression than older White individuals,¹¹ which may reduce the perceived need for mental health services.^6,12 Because somatic symptoms of depression among older adults, such as significant change in weight, sleep, and appetite, may be underdiagnosed or misdiagnosed as normal signs of aging, there is a critical need to examine depressive symptoms among older African American populations and their mental health care.

While women are generally at greater risk of experiencing depressive symptoms, there is evidence to suggest that older African American women with poor self-reported health and low social support have higher rates of depression and limited activities of daily living than White women and are more susceptible to experiencing severe depressive symptoms.⁵ Moreover, African American women with depression and hypertension were found to be more likely physically impaired than African American women with hypertension but no depression.⁹ There is a growing body of literature associating depression with hypertension. However, to our knowledge to date, there is only 1 study that has quantified depression among hypertensive African American women.^8,9,13-25 Abel et al²⁵ reported that depression was associated with higher disease burden (ie, the number of comorbidities), lower active coping, and worse medication adherence as measured by the Hill-Bone Compliance to High Blood Pressure Therapy Scale.²⁵ The association between hypertension and depression is inconclusive; a few studies have found no link between the 2 in other populations.^26-28 The paucity of research examining this associations among African American women highlights the need to quantitatively examine depressive symptoms among African American women with hypertension while accounting for their age, SES, and other preexisting conditions.

The Prime Time Sister Circles randomized clinical trial (PTSC-RCT) is an ongoing study designed to determine whether the PTSC intervention can help low income, mid- to late-life urban-dwelling African American women with hypertension better control their blood pressure. The PTSC intervention includes primary and secondary strategies that address contextual factors shaping cardiovascular disease outcomes among African American women: education (knowledge about hypertension sequalae); behavioral (self-reported adherence); risk factors for hypertension and cardiovascular disease (eg, poor nutrition, inactivity, and increased stress); psychosocial (ie, stress management and self-efficacy to manage blood pressure); clinical (blood pressure control, waist circumference, and body mass index); and health care use (hospitalizations and inpatient admissions). Depressive symptoms are one of the secondary outcomes in the PTSC-RCT study. This study presents the baseline data for depressive symptoms. In the future, we will address the effect of the intervention on the participants. In this study, we conducted a cross-sectional analysis of PTSC-RCT participants at baseline to explore the prevalence of depressive symptoms, risk factors of depression, and use of mental health care services.

Data for this study came from the PTSC-RCT. The PTSC-RCT was approved by the institutional review boards of the Johns Hopkins Bloomberg School of Public Health and the American Institutes for Research. The study population includes 341 English-speaking women who self-identify as African American, are aged 40 to 75 years, have a diagnosis of hypertension (defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg), received their primary care at a federally qualified health center (FQHC) in Washington, DC, in 2017 and 2018, and were flagged by the FQHC as having uncontrolled hypertension (Figure). Participants were invited to a recruitment meeting to learn about the PTSC intervention and the study design and then to provide written consent to participate and complete a baseline survey. Twenty-five participants were removed from analysis because they had missing data for the 10-item Center for Epidemiological Studies Depression Scale, Revised (CES-D-10). Twelve participants did not answer the CES-D-10 and 13 participants had missing data for 2 or more items. The final analytical sample was reduced to 316.

Depressive symptoms were measured using an adapted, 10-item version of the Center for Epidemiologic Studies Depression Scale Revised (CES-D-R) (CES-D-10), adopted from the Center for Epidemiologic Studies Depression Scale.²⁹ This version has an internal consistency with Cronbach α = .86 and test-retest reliability for individual items by intraclass correlation of 0.11-0.73.³⁰ We used the CES-D-10 because it is an appropriate measure for a community sample, and the PTSC is a community-based intervention.

Each item is scored on a 4-point ordinal scale for frequency: 0, rarely or none of the time (less than 1 day per week); 1, some or a little of the time (1-2 days per week); 2, occasionally or a moderate amount of time (3-4 days per week); and 3, all of the time (5-7 days per week). Of the 10 items, 8 focused on positive symptoms while the other 2 (items 5 and 8) assessed negative symptoms of depression. The total score is calculated by finding the sum of 10 items after reversing items 5 and 8. This approach yields a maximum score of 30. Following the CES-D-R guidelines, any score equal to or greater than 10 is considered as exhibiting significant depressive symptoms (hereinafter, participants with CES-D ≥10 are referred to as participants with symptoms of depression and participants with CES-D <10 as participants without symptoms of depression).³¹ We recognize that CES-D is a depression screener and identifies symptom of depression and it is not a clinical definition of depression.

We used the 10-score outpoint and compared socio-demographics (age and marital status), SES (educational attainment and annual income), health insurance status, health behavior variables (current tobacco use and/or alcohol consumption), number of chronic conditions (diabetes, high blood cholesterol, heart disease, cancer, stroke, and obesity), and self-reported health care use for depression (whether they visited a mental health professional or health care professionals in the last 6 months, were hospitalized in the past 6 months owing to mental health conditions, or were diagnosed by a health professional for depression and are being treated for depression) between participants with and without symptoms of depression. Participants who indicated that they never drink alcohol or smoke were classified as nondrinkers or nonsmokers.

We used unequal t tests to determine whether there were significant differences between participants with and without symptoms of depression for the total CES-D-10 score scale, socio-demographics, health insurance status, health behavior variables, number of chronic conditions, and self-reported health care use for depression.

To address missing values for control variables, we have used the multiple imputation technique. The multiple imputation is a simulation-based statistical technique to handle missing data.³² We used Stata (StataCorp) to perform multiple imputation to treat incomplete values of control variables including age, marital status, education, income, health insurance coverage, smoking, and drinking behaviors, and we reported percentage of missing values for these variables in Table 1. We used logistic regression with multiple imputation to investigate the associations between a dichotomized version of the original CES-D-10 score and factors among PTSC-RCT participants. The first sets of models were univariate logistic regression to investigate the associations between the CES-D-10 score and various factors (age, marital status, education, income, health insurance status, smoking status, drinking status, and number of chronic conditions). The second model was a multivariate logistic regression model including all mentioned control variables. All statistical procedures were conducted using Stata, version 15 (StataCorp).

For this analysis, we used baseline data from the PTSC-RCT study. Table 1 displays the distribution of characteristics among the PTSC-RCT participants by CES-D-10 scores. Among the participants, 57.0% scored 10 or greater on the CES-D-10. Participants with symptoms of depression scored significantly higher on the CES-D-10 (mean [SD], 15.8 [4.5]) than participants without symptoms of depression (5.7 [2.3]). Women whose CES-D-10 scores were 10 or more were, on average, 2 years younger (age 56 years vs 58 years), less likely to have more than a high school education, less likely to have an annual income between $20 001 and $40 000, and more likely to currently smoke and have higher number of chronic conditions compared with women whose CES-D-10 scores were less than 10. More than one-third of participants with symptoms of depression reported that they have stayed in bed for more than half of the day owing to depression in the past 6 months.

Table 2 displays the self-reported mental health care use among PTSC-RCT participants. Participants with symptoms of depression were more likely to have seen or talked to a mental health professional, seen a health care clinician for depression, and used any aforementioned services than participants without symptoms of depression. Participants with symptoms of depression were also more likely to have been told by a physician that they have depression compared with participants without symptoms of depression. Eighty-five percent of depressed PTSC-RCT participants reported receiving depression treatment within the last 6 months. The source of treatment varied. In the 6 months prior to their involvement in the study, 52% of depressed PTSC-RCT participants (n = 87) had seen a mental health clinician and 29% (n = 52) had seen a health care clinician for depression. However, 15% (n = 27) had not seen a health care professional, and almost one-third (n = 53) reported that they had not been diagnosed as having depression by a physician. Approximately 34.4% of depressed PTSC-RCT participants (n = 62) reported that they stayed in bed more than half of the day owing to depression during the past 6 months, indicating that, for a considerable segment of the study population, depression has had a negative effect on their lives. (Table 1).

Table 3 displays odd ratios (ORs) of the association between factors and CES-D-10 score among PTSC-RCT participants. The unadjusted ORs confirm the observations made in Table 1. The following factors were associated with better depressive outcomes: having greater than a high school education (unadjusted OR, 0.492; 95% CI, 0.265-0.916; adjusted OR, 0.492; 95% CI, 0.249-0.968) and annual income between $20 001 and $40 000 (unadjusted OR, 0.479; 95% CI, 0.263-0.870, adjusted OR, 0.518; 95% CI, 0.275-0.974). Smoking (unadjusted OR, 1.761; 95% CI, 1.113-2.787; adjusted OR, 1.731; 95% CI, 1.039-2.881) and having multiple comorbidities (unadjusted OR, 1.199; 95% CI, 1.025-1.404; adjusted OR, 1.235; 95% CI, 1.046-1.460) were associated with increased risk of being depressed. We did not find significant associations with depression and age, annual income greater than $40 000, health insurance status, and drinking behavior. We conclude that income is associated with better depressive outcomes despite the insignificant results for women with incomes greater than $40 000 because this group is less than 5% of the sample. The small size yields an estimate with a large standard error.

Little is known about the prevalence of depressive symptoms among low-income, midlife African American women with hypertension. However, given that hypertension is a major contributor to disparities in cardiovascular morbidity and mortality among African American women, it is important to examine the extent to which experiencing depressive symptoms circumscribes the ability of African American women and their health care clinicians to successfully manage their blood pressure. In this study, more than half of the participants scored 10 or higher on the CES-D-10, and 85% of participants with symptoms of depression had received some form of mental health services within the past 6 months, with more than half seeing a mental health professional. We also found that having more than a high school education and a higher income served as associative factors, while smoking and having multiple comorbidities served as risk factors. These findings shed light on the mental health of low-income, older African American women.

A 2019 study³³ suggests that African American individuals are less likely to report depressive symptoms and that their professionals are less likely to recognize their presentation of depression.³³ We contrast these findings with those observed in our analyses comparing depressive symptomology and mental health care use at baseline among mid- to late-life African American women in Washington, DC. We found that 85% of participants with symptoms of depression had received some care for their depression, with more than half seeing a mental health professional. However, given that PTSC-RCT participants continue to report depressive symptoms, our findings suggest that the treatment they are receiving may not be effectively addressing their mental health problems.

The PTSC-RCT can shed light on depression and mental health of low-income, older African American women with hypertension. We observed that age, having more than a high school education, and a higher income were associated with better depressive outcomes, while smoking and having multiple comorbidities were associated with worse depressive factors.

While we found that women with symptoms of depression in the PTSC-RCT were less likely to report being happy or hopeful about the future, other studies have observed that African American women exhibited resiliency linked to John Henryism^13,34 (“a strong behavioral predisposition to cope actively with psychosocial environmental stressors)³⁵ and religious/spiritual beliefs.³⁶ Abel et al²⁵ found that active coping, as measured by John Henryism Scale of Active Coping, was protective for depression among African American women with hypertension and posit that high John Henryism may be consistent with “strong Black women” ideology.²⁵ Blonder et al³⁶ found a negative association between the John Henryism Scale of Active Coping and depressive symptomatology.³⁶ Their sample consisted of 314 economically diverse African American women ages 19 to 70 years from a Midwestern city. However, evidence from the Jackson Heart Study suggests that greater John Henryism is linked to an increased risk of depression for African American individuals.³⁷ While certain depressive symptoms may be associated with life circumstances, such as trauma, loss, poverty, and disempowerment,⁷ participants may have also suppressed other aspects of depression (sadness and/or hopelessness) to cope with prolonged stress from societal pressures and racial, sex, and class discrimination.^8,13-16 This may be an indication of some resiliency among these women despite their difficult circumstances. This is consistent with data from the Gallup Healthways survey that shows that low-income Black individuals are more optimistic about the future and are more happy than comparable White individuals.³⁸

This study should be interpreted within its limitations. At baseline, the results are cross-sectional, so the chronicity and onset of depressive symptoms could not be examined. Because the PTSC-RCT samples African American women who are low SES, have routine care, and have hypertension, results may not be generalizable to African American women who have higher income, are not hypertensive, and/or do not see a health care professional regularly. Our measure of depressive symptoms may be biased because of missing data. We excluded 25 PTSC-RCT participants who did not answer the CES-D-10 or partially completed the CES-D-10. However, some of the women did endorse a few depressive symptoms, with 4 having a score greater than 10. This study does not confirm the association between hypertension and depressive symptoms; rather, it elucidates the prevalence of depressive symptoms among low-income African American women with hypertension.

However, this study has several strengths. Our results contribute to growing literature concerning the mental health of older African American women. The PTSC-RCT provided a large convenience sample of low-income African American women with hypertension. We observed a fairly homogeneous vulnerable population who were concordant with respect to race/ethnicity, socioeconomic, and demographic characteristics, health status, and geography. The women in this sample also received care from an FQHC, which suggests that undiagnosed depression may not be owing to a lack of access to care. We measured depressive symptomology through the validated CES-D-10 questionnaire. Given that the CES-D-10 is widely used, PTSC-RCT results can be compared with nationwide survey results.

Our findings expand our understanding of depression prevalence among low-income mid- to late-life African American women. They also have implications for the PTSC program and other peer-based interventions seeking to reduce chronic disease disparities among African American women. Equipped with this information, facilitators in the PTSC-RCT can support participants’ mental health care by raising awareness of depression and normalizing it, increasing knowledge of healthy coping strategies, reducing stigma associated with depression, and encouraging participants to recognize symptoms of depression and seek help.² Additional peer-based studies can examine the influence of support groups in assisting participants with improving their mental health.² Subsequent PTSC-RCT investigations are well poised to evaluate progress made in participants’ knowledge of depression, coping mechanisms, John Henryism, religious/spiritual beliefs, and the use of mental health care during follow-ups. Finally, because the women in this study receive their health care at an FQHC, our findings highlight the need for integrated mental health care for women who are already being treated for hypertension. The FQHC clinicians should screen low-income African American women with hypertension for depression and ensure that those who screen positive are referred for treatment for depression. The FQHC clinicians should also monitor the quality of their depression care to ensure that the women are receiving effective treatment.³⁹

Corresponding Author: Darrell J. Gaskin, PhD, MS, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Hampton House, Ste #441, Baltimore, MD 21205 (dgaskin1@jhu.edu).

Accepted for Publication: December 9, 2020.

Published Online: February 10, 2021. doi:10.1001/jamapsychiatry.2020.4622

Author Contributions: Drs Gaskin and Zare had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Jones, Yang, Balamani, Gaston, Porter, Gaskin.

Acquisition, analysis, or interpretation of data: Gabriel, Zare, Jones, Yang, Ibe, Cao, Woods, Gaskin.

Drafting of the manuscript: Gabriel, Zare, Cao, Gaskin.

Critical revision of the manuscript for important intellectual content: Gabriel, Zare, Jones, Yang, Ibe, Balamani, Gaston, Porter, Woods, Gaskin.

Statistical analysis: Zare, Yang, Cao, Gaskin.

Obtained funding: Gaskin.

Administrative, technical, or material support: Gabriel, Ibe, Cao, Balamani, Gaston, Porter, Woods, Gaskin.

Supervision: Gaskin.

Conflict of Interest Disclosures: Drs Zare, Ibe, and Gaskin reported grants from National Institute on Minority Health and Health Disparities during the conduct of the study. Drs Jones and Yang reported grants from the National Institutes of Health during the conduct of the study. Dr Gaskin reported grants from the US Centers for Disease Control and Prevention, Abell Foundation, and the Pew Foundation outside the submitted work. No other disclosures were reported.

Funding/Support: Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health R01MD010462.

Role of the Funder/Sponsor: The National Institute on Minority Health and Health Disparities had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health.