By Steve Manas
The disparities remain despite improvements to diagnostic tools and therapies in the two last decades, according to a study published online in American Journal of Public Health.
Depression is a significant public health problem for older Americans—about 6.6 percent of elderly Americans experience an episode of major depression each year and can complicate medical conditions commonly found in the elderly, including heart failure, diabetes, and arthritis.
“If untreated or undertreated, depression can significantly diminish quality of life,” says Ayse Akincigil, assistant professor of social work at Rutgers. “Vigorous clinical and public health initiatives are needed to address this persisting disparity in care.”
For the study, researchers culled data from the U.S. Medicare Current Beneficiary Survey, 2001-2005 to get information on health care use and costs, health status, medical and prescription drug insurance coverage, access to care, and use of services.
Based on a national survey of 33,708 Medicare beneficiaries, depression diagnosis rates were 6.4 percent for non-Hispanic whites, 4.2 percent for African Americans, 7.2 percent for Hispanics and 3.8 percent for others. The heterogeneity of Hispanics makes it difficult to determine why they are undertreated and their treatment preferences, Akincigil says.
“Are there cultural differences or systemic differences regarding health care quality and access for treatment of depression?” Akincigil asks. “If African Americans prefer psychotherapy over drugs, then accessing therapists for treatment in poorer neighborhoods is a lot more difficult than it is for whites, who generally have higher incomes and live in neighborhoods more likely for therapists and doctors to be located.
“Whites use more antidepressants than African Americans. We presume they have better access to doctors and pharmacies, and more money to spend on drugs.”
The investigation focused on whether there are racial/ethnic differences in the rate of diagnosis of depression among the elderly, controlling for sociodemographic characteristics and depression symptoms (depressed mood, anhedonia) reported on a two-item screener, and also in treatment provided to those diagnosed with depression by a health care provider.
There is evidence that help-seeking patterns differ by race/ethnicity, contributing to the gap in depression diagnosis rates. Stigma, patient attitudes, and knowledge also may vary by race and ethnicity.
“African Americans might turn to their pastors or lay counselors in the absence of psychotherapists,” she said. “Low-income African Americans who were engaged in psychotherapy reported that stigma, dysfunctional coping behavior, shame, and denial could be reasons some African Americans do not seek professional help.”
The nature of the patient-physician relationship also might contribute to disparities in depression diagnosis rates.
“African Americans reported greater distrust of physicians and poorer patient-physician communication than do white patients. Communication difficulties may contribute to lower rates of clinical detection of depression because the diagnosis of depression depends to a considerable degree on communication of subjective distress,” Akincigil explains.
Racial and ethnic differences in the clinical presentation of depression may further explain the lower rates of depression detection among African-American patients.
Financial factors may also play a role in the detection rates. Among Medicare beneficiaries, African Americans are substantially less likely than non-Hispanic whites to have private supplemental insurance that covers charges larger than standard Medicare-approved amounts.
“Differences in provider reimbursement may favor increased clinical detection of depression in white patient groups if higher payment rates result in longer visits,” Akincigil says.
The study concludes that “efforts are needed to reduce the burden of undetected and untreated depression and to identify the barriers that generate disparities in detection and treatment.
“Promising approaches include providing universal depression screening and ensuring access to care in low-income and minority neighborhoods. An increase in the reimbursement of case management services for the treatment of depression also may be effective.”