A rocky foundation
For more than 400 years, resilience for people of the African diaspora was essential for survival. The concept of “Black resilience” recognizes the need for “extraordinary strength of mind and body for the sake of psychological and physical survival” (1). The stigmatization of mental illness within the Black community has also been linked to American slavery and scientific racism by historians with a dichotomy of thought: Black people were deemed “subhuman, incapable of mental illness,” and having such an illness showed weakness (2). Because of this stigma, mental illness was often concealed or explained away by an outside, remediable source such as stress or physical ailments, which created barriers to treatment and help-seeking behaviors (3).
The National Institute of Mental Health estimates that 21.4% of Black Americans live with a mental illness (4). In addition, 2021 data from the United States Renal Data System estimate that the overall prevalence of chronic kidney disease (CKD) was highest among Black individuals (18.8%), and a 2022 study found that US adults with self-reported CKD were more likely than those without a chronic illness to experience mental illness (5, 6).
Barriers to appropriate care
The disproportionate burden of CKD and mental illness among Black Americans contributes to health disparities. For individuals willing to seek care for mental health, disparities in access remain a significant barrier, with 10% of Black Americans not having any health insurance compared with 5.2% of White Americans (7). Additional socioeconomic barriers, such as high out-of-pocket costs or unfathomable waiting times for outpatient appointments, often portend emergency departments becoming the main source of mental health care, leading to care fragmentation. Among patients with CKD, the widespread use of race-based clinical equations, such as those used to estimate glomerular filtration rate—until very recently (8)—may also contribute to disparities in timely diagnosis, referral to subspecialty care, access to transplantation, and medical trust among Black patients.
To compound this issue, the scarcity of Black mental health professionals may discourage patients from seeking care due to fear of medical mistreatment or concerns about a lack of cultural familiarity and common ground of the assigned clinician (9). Data from the American Psychiatric Association show that only 2% of the estimated 41,000 psychiatrists in the United States are Black, and just 4% of psychologists are Black (10). As clinicians, we are charged to enter each patient encounter culturally aware, remembering to check our own biases at the examination room door. Unfortunately, we often fall short. One study from 2004, albeit dated, found that physicians speaking with Black patients were 23% more verbally dominant and engaged in 33% less patient-centered care when compared with White patients (9). The complexities of gender/gender identity, sexual orientation, mental health, and chronic diseases merge with these implicit racial biases.
Navigating a path forward
The path forward to advancing mental health equity among individuals living with CKD requires inclusivity among care teams and a recognition of the importance of cultural sensitivity.
The path forward to advancing mental health equity among individuals living with CKD requires inclusivity among care teams and a recognition of the importance of cultural sensitivity. Recognizing the historical origins of mental health stigma and the vital roles of patients’ family and social and faith communities in treatment decision-making is an important first step in understanding the Black experience in any chronic disease. Extended family and shared faith partners are often integral stakeholders in the decision-making process. Continued efforts to promote workforce diversity among kidney care and mental health professionals are needed. Nephrologists should also make every effort to work collaboratively with culturally sensitive mental health professionals to enhance overall care for Black patients living with both CKD and mental illness. Useful resources include the Black Virtual Wellness Directory (11) and the National Alliance on Mental Illness (12).
In conclusion, let us strive to live by the words attributed to the brilliant poet, Dr. Maya Angelou, “Do the best you can until you know better. Then when you know better, do better.” Much is yet to be mastered on this subject; however, we have enough knowledge now to indeed do better.
Footnotes
The authors report no conflicts of interest. Dr. Purnell has received funding from the National Institutes of Health and Agency for Healthcare Research and Quality and serves as a member of the governing boards for the Infinite Legacy Foundation and the National Minority Organ Tissue Transplant Education Program.
References
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O’Malley L. Addressing the lack of Black mental health professionals. November 17, 2021. Insight into Diversity and Potomac Publishing, Inc. https://www.insightintodiversity.com/addressing-the-lack-of-black-mental-health-professionals/
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