In addition to lower chance of diagnosis and treatment, quality of psychiatric services is lower for Blacks as they tend to receive treatments in primary care settings where they seek care for medical conditions (60). Given low access to the healthcare system mistrust, and high stigma, depression is expected to be more consequential for Blacks than Whites (52,54,61). Blacks endorse more negative beliefs regarding pharmaceutical treatment of depression compared to Whites (54), as they have higher tendency to prefer non-pharmacologic approaches (e.g., counseling and prayer), and less frequently believe in high efficacy of depression medications. Blacks have higher tendency to believe that antidepressants are addictive (62). All of these beliefs operate as barriers against depression treatment among Blacks. Thus, improvement of screening, diagnoses, and treatment of depression among Blacks may require enormous efforts (54,63,64).

Multiple disadvantage theory suggests that a new chronic disease or stressor will be more disabling in the presence of multiple conditions and stressors (48). Based on this theory, depression is expected to have more consequences for Blacks than Whites (49). Racial groups differ in number of conditions (28), access to health care, social position, severity of disease (50), and delay until diagnosis and treatment (51) which may explain the stronger effect of depression on self-esteem for Blacks compared to Whites.

Higher effect of MDD on self-esteem of Blacks compared to Whites is compatible by the cumulative disadvantage framework (65) suggesting that the consequences of each risk factor are larger for Blacks. For instance, in a study, Blacks reported a stronger response to life events, than Whites in a variety of domains (66). In a longitudinal study, change in stress better explained change in depression for Blacks than Whites (67). From other aspect, average levels of self-esteem vary across cultures (68). For example, North American children and adolescents show higher total self-esteem scores compared with their Chinese and Japanese counterparts (68). Social identity theory indicates that individuals’ self-concepts are derived from perceived membership of particular social groups (69). Therefore, ethnic identity as an aspect of self-concept may protect individuals from life risks. In line with this, resilience framework also considers self-esteem as a protective factor among youth against stress resulted from negative life events and also as a protective factor against depression (70,71). Cross-sectional studies have also identified a significant negative relation between self-esteem and depressive symptoms for Latino, African American, and White adolescents (71,72). Study findings of Umaña-Taylor  (71) among 1062 Mexican-origin adolescents who were attending schools with various ethnic composition (i.e., predominately Latino, predominately non-Latino, and balanced Latino/non-Latino) indicated that ethnic identity exploration positively predicts self-esteem and that self-esteem partially mediates the relation between perceived discrimination and adolescents’ depressive symptoms (68).

Based on a phenomenon called the Black-White paradox (73,74), despite high levels of medical conditions, depression is not common among Blacks (75). Despite being exposed to a wide range of stressors (76), Blacks have disproportionally low rates of depression (77). Blacks’ low rate of depression despite higher psychosocial stress and chronic medical conditions (76-80) suggests that race mitigates correlates of depression in a wide range of domains. Differential correlates of depression and depressive symptoms among Whites and Blacks may be in part due to racial differences in how depression influences evaluation of self, others, and future (18).

The results reported here have major clinical implications for diagnosis and treatment of depression, as well as handling low self-esteem in diverse populations. We argue that psychotherapies and cognitive behavioral therapies may differently benefit from considering and targeting self-esteem across race groups. To be more specific, health care providers and therapies who treat depression may consider additional focus on dysfunctional attitudes and beliefs about self among Blacks with depression, particularly Black men with depression. Low self-esteem may be a more important part of depression among Blacks, compared to Whites. Future research should also determine direction of the association, whether effect of depression on self-esteem is stronger for Blacks, or Blacks with low self-esteem are more susceptible to depression.

Our study had a few limitations. First, differential validity of measurements for MDD, and self-esteem was not ruled out. In addition, we cannot rule out under-reporting of depression among Blacks (81,82). The validation of the CIDI diagnosis of MDE using the Structured Clinical Interview for DSM-IV (SCID) has shown high validity among Blacks, even higher than Whites (83). Despite the above limitations, our study had numerous strengths. This is one of the first studies on the moderating effects of race on the link between depression and self-esteem. Using a nationally representative sample was an additional strength of the current study.

The extent to which depression deteriorates self-esteem of racial groups is not well known. By the same amount of exposure, responses and consequences of stress depend on race (84). Despite the above limitations, results provided here shed more light on racial and gender disparities in depression. Our results may show one of many ways that explain racial disparities and thus may be helpful for policy makers and program planners to tackle racial inequalities in the United States.

To conclude, Blacks and Whites differ in the link between MDD and self-esteem, with Blacks showing a stronger association between the two than Whites. The stronger link between depression and low self-esteem among Blacks may be one of several mechanisms behind lower health care utilization, as well as worse outcomes associated with depression treatment among Blacks. The mechanism behind differential link between depression and cognitive elements of depression across ethnic populations is unclear (85). Future research is needed on cross-cultural differences in the link between depression and evaluation of self, others, and future. This information may also help us better understand racial differences in outcomes as well as course of depression (86-88).

Acknowledgements

For this analysis, public data set of the NSAL was downloaded from the Interuniversity Consortium for Political and Social Research (ICPSR), Institute for Social Research, University of Michigan.

Conflict of Interest

Shervin Assari and Masoumeh Dejman declare that they do not have any potential conflicts of interest to report.

Funding/Support

Shervin Assari is supported by the Heinz C. Prechter Bipolar Research Fund and the Richard Tam Foundation at the University of Michigan Depression Center. The NSAL is mostly supported by the National Institute of Mental Health, with grant U01-MH57716. Other support came from the Office of Behavioral and Social Science Research at the National Institutes of Health and the University of Michigan.

Authors’ Contribution

Shervin Assari designed the work, analyzed the data, and drafted the manuscript. Masoumeh Dejman contributed to the conceptualization and revision of the paper.

Informed Consent

Informed consent was obtained from all participants. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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