Introduction {#S1}
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Major depressive disorder (MDD) is the fourth leading cause of disability and a leading cause of non-fatal disease burden ([@B1]).  It affects one in five persons in the United States and manifests with symptoms that are physiological, emotional, motivational, behavioral, and cognitive as specified by the *Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition* \[*DSM-IV*; American Psychiatric Association (APA), 1994\]. 

According to a Survey ([@B2], [@B3]), blacks have lower lifetime rates of MDD and equivalent or lower rates of 12-month MDD compared to non-Hispanic whites. 

Blacks have reduced access to mental health services and receive poor quality services as compared to whites ([@B4]).  National co morbidity survey (NCS) reports blacks despite having lower risk of mood disorder, once diagnosed were more likely to be persistently ill ([@B5]). 

For defining purpose, African Americans are black people who do not have ancestral ties to the Caribbean. * Caribbean blacks* are also self-identified as black but they have ancestral ties with West Indies or the Caribbean people. 

Historically, there is a lack of both diagnostic and treatment studies on depression ([@B6]).  This lack of studies on depression in African Americans has existed for decades ([@B7]).  African Americans are underserved, understudied, and misdiagnosed as a group ([@B8]).  In an Afro American study of psychiatric illness ([@B9]), tremendous misdiagnoses were reported. 

Sadness, loss of happiness, malaise, loss of motivation, decrease social interaction, disturbed sleeping, eating and sexual habits, difficulty concentrating, synthesizing, and memory losses are few reported symptoms for Depression.  Non-traditional symptoms may also be sometimes observed in African Americans such as hypertension ([@B6]). 

Discussion {#S2}
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If untreated, depression leads to increased healthcare utilization, which results in emergency room visits from poor quality of life and self-injurious behaviors ([@B10]).  This in turn causes a negative impact on the economy from increased absenteeism and occupational impairment ([@B11]).  It disturbs the family by causing failure to thrive symptoms in children of mothers who have co morbid depression and substance abuse disorders. 

Currently no specific archetype exists for describing depression etiology.  There are several school of thoughts, ranging from organic and physiological factors to biological markers and neurotransmitter deficiencies.  The most acceptable theory for depression considers it as a product of complex interaction between psychological and biological factors.  There exists a positive relationship between depression and stressful life events and a negative relationship between depression and social support ([@B33]).  Precipitants, psychological, or somatic, however can be genetic or acquired predispositions. 

According to World Health Organization report, "The Global Burden of Disease" ([@B13]) depression is considered to be the greatest burden in women when compared to all other diseases.  Women in general are reported to have a higher risk of initial episode and earlier onset of depression as compared to men ([@B12]).  Afro American women have reported three million mental health's visits each year. 

African Americans have a unique history, having been introduced as slaves to this country ([@B8]).  They have distinctive traditions and practices along with extraordinary individual and collective identities ([@B14]).  They are aware of their roles as mothers and homemakers but feel guilty when engaging in activities to promote self-development.  This role conflict in personal developmental and family survival needs often results in depression in African Americans ([@B15]). 

Diagnosing and assessing cultural bound symptoms of depression in African Americans is a major concern.  Difference in symptom presentations between African Americans and other groups can be determined by cultural based expressions.  Cultural competencies are essential for an accurate diagnostic and treatment process designated specifically for each particular racial or ethnic group.  A culture-bound syndrome seen in African Americans is a sudden collapse following an episode of dizziness often referred to as "falling-out."  Sleep paralysis, which is characterized by an inability to move while awakening or falling asleep is also sometimes observed in African Americans ([@B16]). 

According to an estimate nearly half the entire U.S. population will be composed of ethnic and racially diverse people by the year 2052 ([@B6]).  Within this growing pace of diverse race, it is therefore important to realize that statistics peculiar to Whites is not sufficient to address mental health issues among African Americans ([@B17]).  The experiences of racism, sexism, and poverty have increased the risk for depression in African Americans. 

Prevalence of depression in African Americans is reported to be twice as compared to whites ([@B18]). 

National study of American life (NSAL) ([@B20]) survey reports that the lifetime prevalence of depression is higher for whites (17.9%) than for African Americans (10.4%) and Caribbean blacks (12.9%), but when the course of depression is considered, depression in African Americans persists for longer duration.  This measure of persistence was 56.5% for African Americans, 56% for Caribbean blacks, and 38.6% for whites.  Thus, major depression is considered as a chronic disorder for blacks.  Due to the larger exposure to community and domestic violence, African Americans have higher risk for depression co morbidities, such as substance abuse, generalized anxiety and posttraumatic stress disorders ([@B19]). 

Despite three decades of research, treatment of depression and its co morbidities still remains a significant public health problem in the United States.  The treatment of depression and co morbidities is considered to be the most common and urgent concern faced by mental health professionals these days ([@B21]).  Definitive studies for depression treatment in African Americans are sparse.  The higher risk of persisting depression in blacks calls for a need to focus on treatment modalities and identifying causal factors. 

In United States, only 57% of adults with MDD receive treatment ([@B22]).  It is claimed that successful psychotherapeutic treatments for depression are universal and can be applied equally to all racial and ethnic groups, which may well be an invalid assumption ([@B23]). 

In a comparison of cognitive psychotherapy and pharmacotherapy treatments for depression, cognitive psychotherapy was found to be equally effective or more effective than pharmacotherapy at initial treatment and follow-up ([@B24]).  There is a significant reduction in depressive symptoms after 12 sessions of cognitive therapy in African Americans when compared to analytically oriented therapy sessions of similar duration ([@B25]). 

Holistic therapies address physical and psychological symptoms in both diagnostic and treatment modalities ([@B6]).  In African Americans, holistic treatments are found to be successful in reducing depressive symptoms ([@B26]).  An approach to overcome distress and depression is through confronting troubles rather than avoiding them.  Try to seek help from family; friends, neighbors, and religious leaders ([@B14]).  Researchers can take advantage of this particular finding in African Americans to broaden their understanding of the psychological--social strategy. 

The influence of religion in the Afro American inventory cannot be ignored.  Prayer is a common coping response for African Americans in distress.  Today, almost 85% of African Americans describe themselves as "fairly religious" ([@B27]) or "very religious" and "religious involvement" can be a moderator to reduce the onset of depression ([@B28]). 

Ethnicity is a neglected aspect of the heterogeneity of black population ([@B29]).  Although it is important to study racial differences in treatment outcomes, differences between White/Caucasian Americans and Black/African Americans are not typically studied.  When they are reported, the researchers have usually made subsequent comparisons based on samples that are not equally representative. 

It is noticed blacks that do have mental healthcare access receive poor quality care as compared to whites ([@B30]).  Measures should be taken to remove these racial disparities.  Providing equal and quality access to all will help eliminate discrimination and disparities.  Important gaps in mental health status of African Americans continue to exist even after 150 years of 1840 census ([@B31]). 

Conclusion {#S3}
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Blacks, irrespective of ethnicity, are reported considerably more days out of job than the average for persons with Major depression ([@B22]).  This suggests that when blacks develop depression, it is devastating, persistent in course and has poor prognosis.  Clearly, more empirical studies to determine true prevalence rate for depression in African Americans are required to reduce the gap in accessing effective mental healthcare.  This will help close the gap in the literature on effective depression treatments for this underserved and understudied group. 

This article is not meant to propose guidelines for diagnosis and treatment of depression.  It is an attempt to organize our thoughts on misdiagnoses and under treatment of depression in African Americans.  Although this lacks empirical data to substantiate its effectiveness, it serves as a means for setting a framework for future thought on this issue.  Our goal is to draw attention toward more evidenced-based approaches to broaden understanding of diagnostic and management modalities.  Future research also needs to explore how social support systems; psychological funding, acculturation processes, and cultural values could benefit black population improve their mental health ([@B32]). 

Conflict of Interest Statement {#S4}
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The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. 

We would like to acknowledge that this is a selective review article.  An electronic search for the relevant available information of our topic was done.  The keywords Depression, under treatment, African Americans, misconception, underserved, and misdiagnosed were searched in Medline, PubMed, Google, and Google Scholar.  Detailed searches from 1981 to 2011 were undertaken to highlight lack of health care services for African Americans.  More needs to be learned about how and when treatment should be modified to take African Americans needs and preferences into account. 

[^1]: Edited by: Ripu D. Jindal, University of Pittsburgh School of Medicine, USA

[^2]: Reviewed by: Dusan Kolar, Queen's University, Canada; Casimiro Cabrera Abreu, Queen's University, Canada; Ripu D. Jindal, University of Pittsburgh School of Medicine, USA

[^3]: This article was submitted to Affective Disorders and Psychosomatic Research, a section of the journal Frontiers in Psychiatry.