An Analysis of Black Americans’ Substance Abuse and Mental Health

Introduction

It is no longer necessary to prove there is a built in bias against African Americans in the United States (U. S.).  The events of last summer, with the number of Black young men shot and killed by police, and what is occurring in Chicago currently, where Blacks are killing Blacks, are the living, evident proof that the bias and the proper behavior Blacks are displaying by killing one another is what the ruling class Whites wanted and started in the 1660s, with the first slave laws in Virginia colony.  In the U. S., Black Americans are still striving for that American dream of equality and find that even with all the laws made for equality in the latter half of the 20th century, they still are not equal.  Statistics prove bias and inequities exist in modern American society for Black people.

The current state of Black households in the U. S.  Recounting the long, miserable, biased history of African Americans is not the purpose of this examination.  The results of discrimination and hardship are evident in modern society.  For one, that Blacks make up almost 14% of the American population is fact as of the 2010 census (The U. S. Census Bureau, 2015).  The Feeding America organization website (2016) informs readers that “African Americans are disproportionately affected by poverty, food insecurity, and unemployment.  They are also more likely to receive charitable food assistance than their Latino and white, non-Hispanic peers” (para., 1).  The organization also reports that as many as 34% of African American children live in a food insecure home (Feeding America, 2016, para., 6).  Moreover, in the U. S. African Americans households have less to eat, are unstable, and experience unemployment more often than other groups living in the U. S. (Feeding America, 2016).   

Black male life statistics.  Black men have statistically had a lower average of death age, than to White men.  It is sure that poverty and lack of proper healthcare contribute to that number.  US News and World Report (2015) reported “the average African-American male lives five years less than the average white American male” (para., 1).  What makes that figure so ironic is that life expectancy in the U. S. has grown to 79 years for White males.  If a Black man is fortunate enough to make it through his youth, he can expect to live to the age of 74 (Cook, 2015).

One of the statistics that usually jolts most people is the one that reports Black men’s incarceration numbers.  The NAACP (2016) reports that Black men make up 1 million prisoners in a prison system that totals 2.3 million for the entire U. S.  That number is staggering when given the fact that they only make up 14 % of the entire U. S. population.  First, the number indicates there is discrimination occurring, as numbers usually do not lie.  If one goes by population numbers in this country, Whites should be the people jailed most, but they are not.  The health behaviors that Black men have in prison helps contribute to their overall shortened life span.  In jail, they are not fed the most nutritious diet, but they may have more exercise than when out of prison.  

The FBI (2012) reports that there is a significant number of Black-on-Black violent crimes, but there are also a number of White-on-Black crimes, especially those that are committed by the police against Black males and to a lesser extent, females.  There have been 102 Black deaths committed by police in the entire nation in 2014 (Mapping Police Violence, 2015).  Violent behavior can be a result of Blacks not being able to reach their “American Dreams.”  As Poet and Harlem Renaissance participant Langston Hughes wrote, does the dream deferred “dry up like a raisin in the sun/or fester like a sore/ . . . or does it explode?” (Poem Hunter, 2016, lines, 2, 3, 4, 11).  After generations upon generations waiting for equality, the dream deferred in some neighborhoods and resulted with people exploding.  

The constant stress that Blacks live with also has an effect on their health.  Some people have the belief that it is very dangerous to be a Black male in American society.  Noted film director, John Singleton, said his 1991 movie, Boys in the Hood, is a “saga about young Black boys growing up in the ghettos of [LA], . . .  [and] ‘They want us to kill each other off. What they couldn’t do to us in slavery, they are making us do to ourselves’” (Manuel-Logan, 2013, para., 2).  Singleton spoke those words in 1991, yet never were truer words spoken.  There is proof that the American government has been complicit in the demise of Black people, especially Black men.  The most recent attempt has been through substance abuse.

The history of Blacks’ substance abuse.  Living in a society that discriminated against them has not been easy for Blacks.  While there is no direct evidence of slaves’ abusing alcohol or drugs, historians proved that they used other means to relieve their onerous work schedules such as slowing down, or appearing not to understand directions, in other words, playing at being imbecilic when they were not.  U. S. law enforcement was not very concerned with drug abuse in the 1700 or 1800s even though there were many drugs available for the asking.  

In North America, the two main drugs used were alcohol and tobacco, usually in the form of chew.  Elliott (2009) used 1860 census records to show just how little tobacco was produced for smoking in the 1870s because “of the 348 tobacco factories . . . [in] Virginia and North Carolina, only six were making smoking tobacco. The rest were making plug and twist tobacco exclusively. . . ” (para., 12).   There was a problem with opium after the Chinese came to the Gold Rush in 1848.  Banned from working in the gold fields due to excessive taxes, Chinese men opened opium dens in cities like San Francisco and Sacramento.  The authorities were not too happy with having the drug there.  There may have been zoning laws that limited areas where the drug could be smoked too.  Because the U. S. would not have clean water to drink until there were sewer systems installed in urban areas, people relied on drinking beverages that had been heated before imbibing.  Many people chose to drink beer daily.

The Drug Policy website (2017) says that there were local laws against the Chinese where they lived and enacted with regards to opium smoking and other drugs.  The website says “the first anti-opium laws in the 1870s were directed at Chinese immigrants” (para., 4).  It goes on to inform readers that “the first anti-cocaine laws, in the South in the early 1900s, were directed at black men” (Drug Policy, 2017, para., 4).  Thereafter, the first federal act regulating drugs was passed in 1906, called the Pure Food and Drug Act.  The law was President Theodore Roosevelt’s reaction to Upton Sinclair’s exposé on the meat packing industry in Chicago.  One part of the act required that ingredients be listed on a label for all drugs sold in pharmacies, as there were problems with alcohol as an ingredient of many elixirs.  At the time, many concoctions had large amounts of alcohol in them.  It should be noted that the drug laudanum, which is a derivative of opium was openly sold on the market as a pain killer throughout the 19th century, helped relieve a variety of symptoms (Laudanum, 2008).  Made of 90% alcohol and 10% opium, the drug was addictive.  Cocaine was an ingredient in Coca-Cola and they had to remove it from their soft drink when the government started cracking down on the drug (Prescription Drug Abuse History, 2017).   It was finally outlawed in 1928 when the government figured out its addictive properties (Laudanum, 2008).   Drug usage in the 1920s and 1930s was mainly used by musicians, writers, poets, and artists to enhance their creative experiences.  Drug usage was underground, clandestine, and kept secret.  By the 1930s, most narcotics were controlled by the government and anyone who was not in the medical field with a legitimate reason for having the drug could be arrested.  Hollywood studios produced movies on the dangers of drug abuse.  One of the titles was Reefer Madness, a movie produced Grand National Studios in Los Angeles, California (Gasnier, 1936; imdb, 2017). 

Modern drug abuse.  Modern drug abuse began in the 1960s with the hippie generation.  Drug usage came out of the alleyways and into the concert venues by the 1960s.  The new generation of people who were fed up with the government and the way it used people rebelled and openly used drugs during rock and roll concerts.  Most of all the 1960s was a time of change for most people in the U.S.  The U.S. involvement in the Vietnam “War” (police action) was the catalyst for many different occurrences.  People began protesting for their civil rights along with African Americans.  Women, Mexican Americans, Native Americans, and the like each wanted to be recognized as equals.  They were ready to overthrow the patriarchal system the Founding Fathers had set up.  

Before Lyndon Baines Johnson (LBJ) left office in 1969, he created the first agency inside the Justice Bureau to look into illegal drug trafficking and usage.  He named it Bureau of Narcotics and Dangerous Drugs (BNDD) (PBS, 2017). The second step in the beginning of the war on drugs was linking drug usage to the rise in burglaries and theft.  Dr. Robert DuPont used urinalyses tests to determine that people entering jail tested positive for heroin forty-four percent of the time.  Getting addicts onto methadone curtailed thefts in DuPont’s area by forty-one percent.  DuPont’s research connected illegal drug usage and theft (PBS, 2017).

Richard Nixon became president in 1968 and began the process of another war instead in South America against drugs and its producers.  The government decided it had to aggressively attack countries that were harvesting and transporting drugs into the U. S.  Soldiers were coming back from Vietnam addicted to heroin.  Finally, in 1971, Nixon declared a war on drugs.  According to PBS documents, most of the drugs came in from South American countries via several different modes of transportation.  Much of the drugs are coming over the Mexican border via automobiles into the U.S. (PBS, 2017).  

In the 1980s, drug problems become more identified with the regular Black community.  Previously, some Black entertainers smoked marijuana and did harder drugs, but the 1980s was a decade in which it was rumored the government set up Black communities to deal in drugs.  During Ronald Reagan’s presidency, there was a concerted effort to punish people who sold drugs and those who were addicted to them.  Nancy Reagan’s campaign to get youngsters to not take drugs was a simple slogan, “Just Say No.”  The problem is much more serious than one simple slogan could fix.  Ruppert (1999) examined an article about the CIA and setting up Blacks with drugs written by Gary Webb (1996) who was a reporter for the San Jose Mercury News.  According to Webb the CIA and its operatives used crack cocaine — sold via the Los Angeles African-

American community — to raise millions to support the agency’s clandestine operations in Central America.  Since the general public had suspicions about the intelligence agency anyway from its rather spotty past, the articles were pretty believable (Manuel-Logan, 2013, para., 3).

Ruppert (1999) thought that Webb’s research was impeccable, but also that at first Webb was incorrect with his findings.  He would change his mind later.  Ruppert found out that the CIA did bring cocaine from South America into the U. S. and they had trouble getting rid of it.  He also noticed that cocaine usage rose dramatically in African-American communities in Los Angeles, but that the drug was not used by Hispanics.  He points to a sociology report and hospital admission records proving that 

Crack cocaine was particularly devastating for African-American communities. This was . . . by design. In early 1985 USC Sociologists Klein and Maxson researched the phenomenon of crack use. ‘One thing they were unable to explain was why crack was found only in L.A.'s black neighborhoods. ‘The drug,’” the sociologists wrote, at least currently seems to be ethnically specific. ‘Cocaine is found widely in the Black Community in Los Angeles, but it is almost totally absent from the Hispanic areas.’ And the effects of crack use were, indeed, biblical. In 1985 50% of the emergency room admissions in L.A were due to crack. Full-blown cocaine psychosis was occurring as soon as eight months after first use and crack cocaine hit hardest among those African Americans who had some college education and held steady jobs (Ruppert, 1999, paras., 48 & 49).

Ruppert (1999) explained he believed that the CIA had targeted Blacks.  He mentioned another CIA operation in the early 1980s where CIA used heroin to meddle in Iraqi politics.  He also knew that the CIA conducted LSD experiments in the 1950s.  Ruppert (1999) garnered the information from “UCLA Political Science professor Paul Jabber in early 1982” (para., 27).  Jabber . . . “confirmed . . . that the National Security Council and CIA had approved the use of heroin smuggled through Kurdestan, [sic] as a means of (re)arming the Kurds to fight . . . Saddam Hussein in 1975” (Ruppert, 1999, para., 27).  Whatever the case may be, one thing is for certain, certain African American communities within the U. S. got involved in using and selling drugs to the point where it became a problem of epidemic proportion (Delaval, 2014). 

Part of the proof of cocaine usage in Black communities is that gangs, the Bloods and Crips, started selling drugs in the 1980s.  The gangs were founded early in the 1970s, but had little activity selling drugs.  They were formed for protection rather than as economic opportunities (Dunn, 1999).  Dunn (1999) said that gangs in the 1980s could make anywhere from $300 to $500 a day selling drugs as a way to relieve poverty and unemployment.  In fact, Dunn (1999) reported that both gangs “control crack cocaine distribution in many cities around the country. Members of these gangs . . . migrate to other cities, ascertain the narcotics demand in that city, identify the dealers in the city, and figure out the established operations for narcotic sales” (para., 9).  A logical outcome of gang migration and “gang involvement in the drug market has led to an extraordinary amount of violence throughout certain cities due to the members fighting over ‘profitable narcotics trade’” (Dunn, 1999, para., 9).  When both gangs get established in other cities, they do so because they have either family residing in the city or people living there who they consider to be family.  Dunn (1999) wrote it is not very hard to convince others to deal drugs with “the enticement of quick profits. . . .  Crips and the Bloods “‘have migrated throughout the country and are seen in most states and their prison populations’” . . . . (para., 9). 

Concomitantly, as Reagan was having the CIA waging a drug war against South American suppliers, he was also dismantling mental health hospitals.  Before Jimmy Carter left office in 1981, he had “signed the Mental Systems Health Act” designed to promote mental health and give grants to researchers who were looking into mental illness prevention (Torrey, 2013).  Carter signed the act one week before the November election.  As soon as Reagan got in office, he and the Republicans withheld funding, so the Act proved useless.  Torrey (2013) said that both Nixon and Reagan did not understand mental illness.  They did not think that mental illness existed.  Indeed, since both had lived through McCarthy era politics and the communism scare in the late 1940s, Nixon as a close aide to McCarthy, they correlated psychiatry with communism (Torrey, 2013). In fact, Reagan even had a close friend who had two children who had paranoid schizophrenia and never related to the needs of people who suffer from various mental health issues.  Reagan began the process of closing down state mental institutions, but he did not really have a plan for the people he would essentially put out on the streets.  

When Reagan closed mental institutions, there was a rise in private facilities offering room and board for mental patients.  These were for profit homes.  For numerous reasons, housing former mental patients in care homes failed.  Many times, patients ran out of their medications and their conditions or disorders returned.  California had piloted a program in the 1970s that shifted mental patients to private facilities from state mental institutions with poor results.  Had Reagan looked at what occurred to patients in California, closing the mental institutions may not have happened.  The current state of mental institutions in the U. S. is much smaller and underfunded.  Fisher, Geller, and Pandiani (2009) reported 

As a result of service and policy interventions undertaken during the last half of the twentieth century, its final decade saw the U.S. state hospital population at a level just 5 percent of its 1955 peak.  But this reduction had not resulted in the closure of large numbers of the hospitals themselves. Indeed, between 1972 and 1990, as the number of state and county psychiatric beds declined 70 percent, only fourteen of 277 state hospitals closed during the eighteen-year period. Thus, in the early 1990s, with large physical plants having to stay open to serve a dwindling number of patients, SMHA officials redoubled their closure efforts. Many diverted funds from hospital operations, investing them instead in expansion of community-based services. In 1981, for example, state hospitals received an average of 63 percent of SMHA budgets, but that share declined to 32 percent by 2004.  In addition, more-aggressive efforts were undertaken to shift acute treatment to local general hospitals, where, as we noted earlier, Medicaid would pay for it.  As a result, forty-four, or nearly 17 percent, of the remaining 263 hospitals closed between 1990 and 2000 (para., 10).

In the 21st century, mental hospitals will be facilities that will continue to house mental patients who cannot be released into the general population.  Fisher, Geller, and Pandiani (2009) include a discussion of people who are arrested and should be contained within a mental facility and not in jail.  The data reveals some startling information about nonwhite populations.  The authors found these data reveal the growth of two demographic populations that also predominate in the criminal justice environment: males and nonwhites. The proportion of males increased an average of 20 percent between 1991 and 2007 in the eleven states monitored for both years, while that of nonwhites increased an average of 48 percent between 1991 and 2007 in seven reporting states, ranging from 53 percent in Delaware to 158 percent in Massachusetts (Fisher, Geller, & Pandiani, 2009, para., 20).  Thus, it can be assumed that Black males are being admitted to mental health facilities upon arrest and evaluation.

In sum, African Americans can expect to have a shorter lifespan than Whites, have access to drugs they can abuse, are arrested in outrageous numbers in comparison to their population numbers in the general population, and make up a majority of mental patients after evaluation upon arrest.  Repeated discrimination and ill treatment, along with less access to proper foods, less access to jobs that support families, with Blacks killing Blacks, and higher numbers abusing drugs, there is definite proof African Americans have been targeted for extinction.  Black baby boom generation members have seen all of these problems grow more out of hand during their lifetimes, yet some do succumb to the problems created by drug usage and alcohol addiction.  This portion of the American population has been continually underserved in healthcare policies.

This study aims to discover what literature there is on substance abuse, particularly in three different areas.  These three areas are alcohol, prescription drug abuse, and mental illness among African Americans age 50 and older.  It will present information that concisely evaluates what the literature says and what more needs to be accomplished.  As a result of this investigation, there will be a formation of a new public policy that will be devoted to helping these older adults with these specific problems.  The project will be devoted to the public good.  The study will include a cost benefits analysis.  This investigation will utilize data from the Substance Abuse and Mental Health Services Administration (SAMHSA) 2010 to 2016 dataset and results from the 2012, 2013, and 2014 National Survey on Drug Use and Health (NSDUH) collected by the Center for Behavioral Health Statistics and Quality (CBHSQ) to assess the determinants that predict the likelihood of co-occurring disorders (i.e. the coexistence of  both a substance abuse and a mental health disorder) such as alcohol abuse and prescription drug abuse, and depression and anxiety among Black adults age 50 and older (SAMHSA, 2016).  An extensive literature research conducted through PubMed, Medline, and scholarly databases to find articles that include both mental illness and drug and alcohol addiction in African American adults.  However, the study has to first deal with one factor.  The study will need to confirm which came first, mental illness that caused individuals to use drugs and alcohol to cover their problem or that the addictions caused the mental illness.  This is currently a conundrum which the literature will determine.

The study will utilize a systematic review of other studies showing an association between addiction and depression in Black adults.  Additionally, the study will include any scholarly research of meta-analyses of cross-sectional studies with this cohort. Sex will not be an important factor; however, age will be.  Luppino, de Wit, and Bouvy (2010) provided that “longitudinal studies are essential in providing more information on the direction of [public policy]. . . . With this information, prevention and intervention strategies could be improved” (para., 9).

Problem Statement

Substance abuse, particularly alcohol and prescription drug abuse, and the impact on mental health is one of the fastest growing health and social problems among African Americans age 50 and older. This problem is largely attributed to the high numbers of the baby boomer cohort born between the years of 1946 and 1964 who are now aging into their sixties and seventies (Colby & Ortman, 2014). Baby boomers make up the largest segments of the U. S. population, about 78 million, with the first wave reached retirement age of 65 in 2011 at the rate of about 10,000 per day for the next 19 years (Pew Research, 2016). Minority baby boomers make up 18 million of those in the general population (Encyclopedia of Aging, 2016).  By 2030, these boomers will make up approximately 19% of the total projected 83.7 million of older adults aged 65 (U.S. Census Bureau, 2012). As the size of the older population grows, the rate of alcohol and prescription drug abuse among the baby boomers increased from 1.1 percent in 2003 and 2004 to 3.9 percent in 2013, disproportionately affecting African Americans age 50 and older, with men more likely to drink heavily than women (Davis & Ancias, 2012; Caputo et al., 2012). Moreover, unlike the current population of older adults, many baby boomers, particularly African Americans experimented with alcohol and/or prescription drugs in their youths (Colby & Ortman, 2014). Yet, even as the number of Black adults abusing alcohol and prescription drug climbs, and the pervasiveness among them have been called an “invisible and silent epidemic” in public health, the situation remains underestimated, underdiagnosed, and undertreated, although it will be increasingly difficult to remain a hidden problem as the baby boomer generation ages (Ferrell, & Sorocco, 2006; Wu, & Blazer, 2014; Pope, Wallhagen, & Davis, 2010).  Stahl et al. (2014) discussed the Black baby boomer underserved population as at risk adults for deep depression.  The study confirmed that early intervention in this population with life coaching on healthy diet choices using non-stigmatizing methodologies will avoid this underserved population of Black adults going into deep depression.  With the literature research results, this study will ascertain where there are gaps in the literature and produce a new policy that health professionals can implement for this underserved population.

Purpose of Study

The literature search and evaluation will determine what areas are under researched and will determine where more studies need to occur.  The result of the literature study is to ascertain where there are gaps in the literature and what the best course of action will be to add to the discourse of and study of Black adults, mental health, drug abuse and alcoholism.  The purpose of this study will determine the formation of a public policy recommendation or proposal for changes to mental health policies that particularly focus on Black adults in need of mental health services that they formerly covered up with abusing prescription drugs or with imbibing alcohol or both.  

Research Question and Hypotheses

There are several questions and possible hypotheses for this study.  They are:

RQ1-Quantitative: Is there an association between alcohol abuse and mental illness controlling for age, gender, racial/ethnicity, income level, education, cultural background, geographic location, health-related quality of life (HRQOL), lack of health insurance, and access to care among African Americans age 50 and older?

HY1- There is no association between alcohol abuse and mental illness controlling for age, gender, racial/ethnicity, income level, education, cultural background, geographic location, health-related quality of life (HRQOL), lack of health insurance, and access to care among African Americans age 50 and older. 

HY2- There is an association between alcohol abuse and mental illness controlling for age, gender, racial/ethnicity, income level, education, cultural background, geographic location, health-related quality of life (HRQOL), lack of health insurance, and access to care among African Americans age 50 and older. 

RQ2- Quantitative:  Is there an association between prescription drug abuse and mental illness controlling for age, gender, racial/ethnicity, income level, education, cultural background, geographic location, health-related quality of life (HRQOL), lack of health insurance, and access to care among African Americans age 50 and older? 

HY3- There is no association between prescription drug abuse and mental illness controlling for age, gender, racial/ethnicity, income level, education, cultural background, geographic location, health-related quality of life (HRQOL), lack of health insurance, and access to care among African Americans age 50 and older. 

HY4- There is an association between prescription drug abuse and mental illness controlling for age, gender, racial/ethnicity, income level, education, cultural background, geographic location, health-related quality of life (HRQOL), lack of health insurance, and access to care among African Americans age 50 and older.

HY5- There is an association between drug abuse and mental illness that cannot be determined which started first, controlling for age, gender, racial/ethnicity, income level, education, cultural background, geographic location, health-related quality of life (HRQOL), lack of health insurance, and access to care among African Americans age 50 or older.

Theoretical Foundations

This study will utilize Bronfenbrenner’s ecological systems theory that had its beginnings in the 1940s (Bronfenbrenner, 1995).  The theory conceptualizes that humans “encounter different environments throughout” life “that may influence [human] . . . behavior in varying degrees. These systems include the micro system, the mesosystem, the exosystem, the macro system, and the chronosystem” (Sincero, 2017, para., 2).  The introduction to this dissertation provides historical, sociological, and cultural justification for cohort behavior and suggests that these types of actions must be taken into account when studying African Americans, mental illness, and substance abuse.  It is the suggestion of this project that built-in discrimination also is a determinant in Black behaviors toward mental illness and addiction.  Bronfenbrenner’s theory proves that Blacks experience in North America since 1660 has been one of different environments not of their choosing for the most part. 

Nature of the Study

This study will use quantitative methodology with a cross-sectional design effective for testing the effects of the social ecological model using data from SAMHSA noninstitutionalized population before 50 years and after 50 years of age.  The nature of this investigation is consistent with the social ecological framework as adapted from the CDC (2015) study model. The determinants or risk factors in this study include: (a) individual, demographic characteristics, socioeconomic status, substance use and history of alcohol, and prescription drug abuse, and health-related quality of life (HRQOL); (b) interpersonal, cultural background/norms; (c) organizational, access to health insurance and health care; (d) community, geographic location; and (e) policy, promotion of mental health screening and treatment. The focus for this study analysis can help to pinpoint in a cross-section of African Americans age 50 and older the key determinants or risk factors of alcohol and/or prescription drug abuse and its relationship with mental illness, and the unmet need of mental health screening and treatment. Using an article search on Pubmed, Medline, and scholarly databases, showing carefulness as to bias, will determine where there is a gap in research and produce a public policy recommendation that will focus on underserved population of African Americans.

Utilizing a qualitative study would not render the results that this study is looking to find.  There is a need to understand the literature on this subject and where the need is for more studies that will help render better services to this underserved population in the U. S.

Literature Search Strategy

A companion document, Substance Abuse Among Aging Adults: An Annotated Bibliography (Feidler, Leary, Pertica, & Strohl, 2002) provided a quick reference to the types of literature and data sources available on substance abuse among aging adults with a broad search criteria. Four databases (e.g., PubMed, Medline, Cochrane, and Psych), Walden University library, and Google Scholar were examined to locate scholarly journal articles. Original studies published between 2007 and 2016 were reviewed to reflect trends in substance abuse and mental health. The search also encompassed: books, book chapters, articles published in peer-review and other professional journals, and government documents published between 2005 and 2016 as well as other literature that focused on substance abuse for adults age 50 and older, and mental health. Keywords were created for each of these concepts by examining the terminology used, as well as in review papers and the references previously cited to assist in the search of relevant literature.  A dictionary and thesaurus search helped to expand the number of relevant sources which include aging adult substance abuse, and mental health screening and treatment. In addition, to these methods all the keywords were combined with standard keywords from the PubMed, Medline, Cochrane, and Psych databases. Google Scholar was used as the search engine since the index included sources that were not found in the other databases; it was specifically linked to the world catalog, and Walden Collections using the library access links found in the settings dialog box in the search engine provided. Some of the keywords used/yet to be used in this literature review include: elderly African-Americans alcohol use disorder, alcohol addiction, drug use disorder, drug misuse, drug addiction, substance use disorder, prescription drug abuse, substance abuse, access to insurance and care, social ecological model, and mental health illness, screening and treatment.

Literature Review Related to Key Variables and/or Concepts

The literature review will be extensive and may start earlier than 2007 to give a sense of how long African American adults and addiction has been a study cohort.  It may be that it is found that studying Black adult groups has not occurred for more than 20 years, but putting either Blacks or African Americans and addiction into the Google Scholar search engine yielded 25,100 and 46,000 results respectively.  It is obvious that the search words will have to be narrowly defined to yield a narrower selection of articles.  The years chosen for the search just to see if there were any articles dating past 2007 were 1980 and 1997 respectively.  Thus, one place to narrow the selection is to include the age requirement and use adults older than 50 or baby boom generation African Americans or Blacks.  When putting the age qualifiers in the search engine that narrowed the field to under 10,000 articles.  Thus, the key variable here will be to keep adding descriptors until the number of articles can be narrowed even further to a manageable number.

Definitions

The terms African Americans and Blacks will be used interchangeably.  Adults over 50 and the baby boomers or baby boom generation will be used interchangeably as well.  The youngest of the baby boomers is now 53 years of age, so the generation fits well into the scope of African American adults.

Assumptions

Assumptions about this topic are that there are fewer places where African American adults feel comfortable to get treatment for substance addiction or mental illness.  Due to a lack of state health facilities, these people do not have much recourse.  This population is poorer and has less insurance coverage to be able to get help for the disorders from which they suffer.  Making a proposal to a health clinic for their public policy is one way to give Blacks a place to receive help.  Since there are grant monies available from various types of foundations, this study hopes to do a cost benefits analysis and grant research and application to garner funds for the proposed help.  It is assumed that long standing discrimination plays a role in mental illness and substance addiction in this cohort but would be almost impossible to gain any qualitative conclusion due to covert discrimination being immeasurable.

Scope

The scope of this study is descriptive in nature, with conclusions that are only generalized to the African-American population age 50 and older engaged in alcohol and prescription drug abuse and its linkage to mental illness.

Significance, Summary, and Conclusions

The significance of this study is that until very recently, relatively little attention has been given to the phenomenon of mental illness and the abuse of prescription drugs. To date, most of the available literature and textbooks include only a single chapter on substance abuse, particularly focusing on alcohol abuse and prescription drug abuse/misuse among the elderly, with little or no mention of the risk factors and their connection to mental illness. It seems that this conundrum will continue.  This study seeks to understand if alcohol and drug abuse occur concomitantly with mental illness or they are separate phenomenon that feed off one another.  Even then, they focus primarily on the individual-level factors, such as demographics to address this problem. The intention of this study is to contribute to the body of knowledge and address a gap in literature, raise awareness among African-Americans age 50 and older of the multiple determinants or risk factors, and contribute to public policy by changing programs to better meet the needs of this cohort.  The risk factors include demographic characteristics, cultural background, geographic location, health-related quality of life (HRQOL), social economic status, lack of health insurance, and access to care that contribute to the mental illness, such as anxiety, depression, and dementia among this population, and the unmet need of mental health screening and treatment adversely affecting their mental and physical health, and ability to function (SAMHSA, 2015). 

It is certain that, according to Conner et al., (2010), substance abuse and misuse problems affect a significant proportion of older adults, approximately 10 percent, and there are concerns that these numbers are projected to at least double by 2030 with increase in the baby boomer generation that experimented with substance early, started reaching retirement age of 65 in 2011. Substance abuse among older adults primarily involves alcohol and prescription and/or over-the-counter drugs, and abuse of illicit drugs is relatively rare. There is comorbidity among older adults since they combine alcohol with prescription drug, such as for pain with their combined effects having adverse reactions like mental illness, particularly among those with psychological and medical disorders (Cooper, 2012).

The history of Black Americans and acknowledging the society and culture in which they live points to how African Americans are viewed today and how they perceive their place in American life.  It has contributed to some extent to substance abuse and mental illness.  It is important that this underserved population of baby boomers, who lived through some of the worst times of discrimination to see more strides to equality, receive the help they need and may be unaware of the help they need.  It is for certain that there is a long history of drug abuse and alcoholism in this population and it is used as a cover for mental illness or mental illness developed from addiction.  Doing a literature review and a public policy proposal will go to helping Black adults live more fulfilling lives when treated.

Section 2 – Research Design and Data Collection

Purpose of Study

The literature search and evaluation will determine what areas are under researched and will determine where more studies need to occur.  The result of the literature study is to ascertain where there are gaps in the literature and what the best course of action will be to add to the discourse of and study of Black adults, mental health, drug abuse and alcoholism.  The purpose of this study will determine the formation of a public policy recommendation or proposal for changes to mental health policies that particularly focus on Black adults in need of mental health services that they formerly covered up with abusing prescription drugs or with imbibing alcohol or both.  

Research Design and Rationale

This section will outline the research design and the rationale for doing the research design for this particular study.  The study will cover methodology, the population size for this study, which will include African American adults aged 50 and older.  That population if using baby boomer population for African American statistics is approximately 18 million.  The study will perform a search for literature on Blacks and African American adults or baby boomers suffering from prescription drug misuse, alcohol addiction and mental illness.  These words will narrow the number of articles that can be safely reviewed in this dissertation.  The information will be gathered using several different database searches including but not limited to Google Scholar, Pubmed, Medline, and additional databases to find articles with those research parameters.

The history of discrimination against Blacks in the U. S. continues and while there is no way to measure the extent of discrimination against this population, there are issues that still effect this cohort.  To give a modern example, the words to “Formation” by Beyonce are very angry and hate filled at that discrimination and the lyrics conclude that the only way to rise above discrimination is to be rich.  The song takes in an angry view of Blacks for generations and the singer is just brilliant enough to put it into a song for her major listeners.  It is doubtful most White listeners would not get the meaning behind that very angry song.  The song acknowledges discrimination and treatment of Blacks without ever using the words.  Thus, discrimination is in the background but nevertheless prominent. 

The second part of the dissertation study will gather statistical information from various websites that collect data on American health patterns.  SAMHSA has five types of data collection or datasets: (a) Emergency Department Data that provides information on drug-related emergency visits, (b) Substance Abuse Facilities Data /NSSATS that provides annual census reports of all substance abuse treatment facilities in the United States, both public and private, (c) Mental Health Facilities Data /NMHSS, which provides annual survey reports of all known mental health treatment facilities in the United States, both public and private, (d) Client level data/TEDS, which contains the demographic characteristics and substance abuse problems of admission to treatment facilities and discharge in the United States, and (e) Population Data/NSDUH considered as the primary source of information on the prevalence, patterns and consequences of alcohol, tobacco, and illegal drugs use and abuse and mental disorders in the U.S., civilian, and non-institutionalized population age 12 and older. The survey generated estimates at the national, state, and sub-state levels. This multi-level study collects data primarily from NSDUH dataset as the primary source of statistics information on the use of alcohol, and prescription drug and mental health disorders among U.S. households aged 12 to 17, 18 to 25, 26 to 34, 35 to 49, and 50 and older. The data was collected for non-research public health surveillance purposes, therefore informed consent is exempted in this situation since this study is merely a monitoring and evaluation investigation (NSDUH, 2014).

Data Analysis Plan

The logistic regression model will be used to perform statistical analysis.  This model is considered to be an important tool used to assess the association between alcohol abuse and prescription drug abuse, the independent (exposure or predictors) variables, and mental illness, the dichotomous dependent (outcome or response) variable. The logistic regression analysis will tell me how much an increment in a given exposure variable affects the odd of the outcome. Multiple logistic regression analysis will be performed to isolate the relationship between alcohol abuse and prescription drug abuse and mental illness from SAMHSA and to adjust for confounding by holding constant age, gender, racial/ethnic status, socioeconomic status, geographical location, health-related quality of life, health insurance status, and access to care. 

The size of the study’s first part will depend on the number of articles reviewed.  This number is yet to be determined as the number will be determined by search engine wording.  Doing a literature review will not require any licensing.  The resulting public policy proposal should not require any licensing as well.  The dissertation should be copyright ready.   The second part of the dissertation will comprise statistical information obtained from SAMHSA, CDC, NSDUH and NIAAA.  The size of this part of the study will depend on the population statistics provided by these data collection sites.

The instrumentation and operational constructs are limited by the words used in the search engine.  The idea is to be as narrow as possible with wording so that the study has enough research articles to determine a lack in the overall research on this population.  The initial basis for this study was a lack of initial research on Blacks over the age of 50 and prescription drug abuse and the combined effect of mental illness.  

The current research instrument utilized a quantitative analysis of secondary data collected by SAMHSA NSDUH in 2014. For this study, the instrument used is the Population Data/NSDUH 2014, a component of the Behavioral Health Services Information Services (BHSIS) maintained by the Center for Behavioral Health Statistics and Quality (CBHSQ). The National Survey on Drug Use and Health (NSDUH) is a national survey system and is the primary source of information on the prevalence, patterns, and consequences of alcohol and prescription drug use and abuse and mental health in the general population aged 12 years and older. The NSDUH uses a computer-based questionnaire that has the capacity to be interactive and bilingual (SAMHSA, 2014).  The research articles selected for this review will either confirm or deny the CDC’s data.

Scientists know that some drugs interact differently in older adult brains to cause them to have dementia or some other mental illness.  Likewise, mixing drugs and alcohol is not advised for anyone taking medication at any age, let alone older adults.  Moreover, medical personnel know that Black men react differently to drugs that reduce hypertension.  The same hypertension prescription will work well for White males but does little to help Black males suffering from high blood pressure, thus the lower age for death in Black males (CDC, 2014).  It is important to know that other drugs may react differently in different populations present in the U. S. due to differences in body or brain chemistry, which is why there may be a larger population of Black adults suffering from mental illness due to addiction than previous studies provide proof of.

According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA, 2011), because adults 65 and older are highly susceptible to the effects of alcohol it is recommended that they should have no more than seven drinks a week and no more than three drinks on any one day. One drink is equal to one of the following: (a) one 12-ounce can or bottle of regular beer, ale, or wine cooler, (b) drinking one regular can or bottle of malt liquor, (c) a half full glass of white or red wine equaling five ounces, and (d) a shot glass full of hard liquor straight that is 80 proof.  Thus, there needs to be a further determination if these statistics include Black Americans and what the results of drinking more than one drink a day have on this cohort.  

Operational variables have yet to be determined but will be placed in this section when the information is completed.  The variables will be the words placed in the search engine.  Each article search will have a different set of variables or words.  Only when the set of articles is determined, will the variables be known.  Other variables may be sex and gender, educational level, marriage status, geographical location, and income.

Threats to Validity

The threats to validity are to first have bias when choosing one article over another for the review.  That is why the search words are so important and the structure of article selection should be bias free but decisions made on the information, not bias.  There will be articles that will be dry to read, but that is the nature of research.  The information is more important.  It would be horrible to not have enough articles to include in the review, but with preliminary searches there seemed over an adequate amount from which to choose one the words will be narrowed further.

Ethical procedures rely on the researcher to be honest in their database searches with the words used.  Most importantly, the writer must write an original dissertation that is properly cited using APA methods and does not include plagiarism of any kind.  The only treatment of the data collected will be to truthfully report where the gaps in literature arise and suggestions for more study and in what areas.  The data will be used to create public policy and a future article talking about the gap in research so other researchers can design a new study.

SAMHSA Guidelines on Screening and Substance Use.  According to Sorocco and Ferrell (2010), several screening assessments tools have been recommended that can be used by medical, mental health, and social services practitioners for alcohol use in the over-60 age group. This study will readjust for age 50.  These tools include: the CAGE Questionnaire and the Michigan Alcohol Screening Test- Geriatric Version (MAST-G) to screen for alcohol use among older adults, the Alcohol-Related Problems Survey, and the Alcohol Use Disorders Identification Test (AUDIT) for identifying alcohol problems among older members of ethnic minority groups. These tests passed ethical guidelines.  In addition, there are age-appropriate psychological treatment interventions that include: brief interventions, family interventions, motivational counseling, and cognitive behavioral therapies. 

Also, to assess substance abuse at various dimensions of an older adult’s suspected problem in stages so that unnecessary tests are not conducted use of a sequential approach and two structured assessment instruments is recommended: The Structural Clinical Interview for DSM-III-R (SCID), a multimodule assessment that covers: substance use, psychotic, mood, and anxiety disorders, and the Diagnostic Interview Schedule (DIS) for DSM-IV, a highly- structured interview that does not require clinical judgment and can be used by non-clinicians. The DIS is available in a computerized version.

Summary of Design

The design for this study will be extensive database searches looking for research on studies done with African American population over the age of 50 and substance abuse and mental illness.  Once the search words are determined the articles will be categorized by that search design.  There will be several different words used.  The articles will be separated by their databases and recorded.  Then they will be cross referenced for information.  Then they will be cross referenced for lack of information.  The areas that lack information are the areas of interest in this study design.  These will inform where there are gaps and where scientists or researchers need to go next with their research.  A future article will be made out of this information once the dissertation is approved.  However, part of the dissertation will be a public policy proposal for change in how African Americans over 50 are treated with regards to drug abuse, alcohol addiction and mental illness.  This study is focusing on this particular cohort because they are underserved in the general health population for various reasons.

This particular cohort has been underserved in the U. S. in many different ways.  There are many variables that lead them to be underserved.  First, there is still discrimination occurring toward this population; however, the discrimination is mostly covert because of civil rights laws passed in the 1950s, 1960s, and 1970s that federally guarantee equality.  The 14th and 15th Constitutional amendments also guaranteed them equality and due process of law, but that did not occur because there were no federal forces to make people, especially southerners, adhere to the laws.  It was not until the 1960s that federal agents got involved in punishing people who killed Black Americans that heretofore had never been punished for murdering them. But for the 300 or so years previous to the 1960s there had been inculcated falsehoods about African Americans such as they take drugs, they are stupid, they were not fit to be in the company of Whites, not showing deference to White women could get Black men jailed or even murdered, or protesting their treatment could get them jailed or murdered.  With good reason, Blacks are leery of what White people can do to them.  There is much distrust toward Whites by Blacks.  They were usually denied healthcare if the town in which they lived did not have a Black doctor.  All of these things are still a part of what Blacks remember of how it used to be, and to some extent still is covertly.  Some people reacted to racism by taking drugs or drinking alcohol in the past; however, since the 1960s there has been more recreational drug usage than ever before.  

According to current literature, the aging process involves many psychological, social, and health issues that contribute to alcohol use or abuse more among older adults than young adults or adolescents. (Gossup & Moos, 2008). Psychological problems commonly associated with older adults indulging in alcohol abuse include: depression, loneliness, and anxiety, which can be problematic due to significant percentages of binge drinking and heavy drinking associated with mental health risks that greatly impact their quality of life (SAMHSA, 2012, Blow & Barry, 2014, Socorro & Ferrell, 2006, Gossop & Moos, 2008). The National Survey on Drug Use and Health revealed that 8.3 percent of older adults aged 65 and older reported that they participated in binge drinking, and 1.7 percent participated in heavy drinking (SAMHSA, 2012).  The CDC (2014) conducted a study on alcoholism from 2009-2011 which resulted in delineating the groups of people who drank within the past year in which they conducted the study.  The portion of the population for Black participants showed that only 3.7 percent were alcohol dependent in that year (Table 1).  However, the statistics changed for Black Americans when socioeconomic, education, and employment status were taken into context.  Then the number rose to 12.6 percent depended on alcohol (CDC, 2008, Table 1 and Table 2).  These tables were not the easiest to read and gather information from but at least they had separated out the Black population who relied on alcohol more than the normal individuals.  The population that was over 65 (the next to the last group was 45-64) did not have a break down for Blacks or any other population group for that matter.  The study did find that highest incident of alcoholism were among Native American populations, but that is not a surprising statistic.  The portion of the population over 65 who drank to excess was 2.6.  So the number for Black adults drinking in that age group would have to be lower than that number, which signifies it is not a large of a problem as once thought.  

Moreover, statistics show that in 2014, 13% of adults ages 65 or older had some form of depression. The symptoms indicating one might be depressed include a loss of interest in life and activities that one usually liked, disturbed sleep patterns, unexplained weight loss, a weight gain, no energy, sleeping more than usual, feeling unworthy, moodiness, extreme guilt, difficulties with concentration, noticeable restlessness or slow movements, and frequent suicidal thoughts.  The symptoms of anxiety include: constant worry and nervousness, panic, insomnia and other sleeping problems, and memory loss and concentration problems (SAMHSA, 2016).  The statistics do not include why older adults get depressed, but some prescription drugs can have those side effects on people.  Alcohol is also a depressant. 

The CDC (2008) also reports that at least 20% of adults aged 55 and older were subject to mental health issues.  The CDC (2008) reported that, Depression, a type of mood disorder, is the most prevalent mental health problem among older, mental, and social functioning. The presence of depressive disorders often adversely, incur higher outpatient charges, and stay longer in the hospital. 

Although the rate of older adults with depressive symptoms tends to increase with age, depression is not a normal part of growing older. Rather, in 80% of cases it is a treatable condition (8). Unfortunately, depressive disorders are a widely under-recognized condition and often are untreated or undertreated among older adults (CDC, 2008, p. 2). These statistics do not break out Black population from the adult population who suffer from mental disease.

This study is important because the Black population is underrepresented in statistics.  What the literature review will do is devote the findings to this cohort and design better ways to help this particular population live a more fulfilling life in the time they have left on this earth.

References

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Blow, F. C., & Barry, K. L. (2014). Substance misuse and abuse in older adults: What do we need to know to help? Journal of Generations, 38(3), 53-67.

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