Diagnosis, treatment of depression among elderly depend on racial, cultural factors

In the study "Racial and Ethnic Disparities in Depression Care in Community-Dwelling Elderly in the United States," lead author Ayse Akincigil, an assistant professor in Rutgers' School of Social Work, and colleagues found that African Americans were significantly less likely to receive a depression diagnosis from a health care provider than were non-Hispanic whites. In addition, those diagnosed were less likely to be treated for depression.

"Vigorous clinical and public health initiatives are needed to address this persisting disparity in care," she said.

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. "If untreated or undertreated, depression can significantly diminish quality of life," Akincigil said. In addition, depression can complicate such medical conditions commonly found in older populations as congestive heart failure, diabetes and arthritis.

For their study, Rutgers researchers culled data from the U.S. Medicare Current Beneficiary Survey, 2001-2005 obtaining 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 said.

"Are there cultural differences or systemic differences regarding health care quality and access for treatment of depression?" Akincigil asked. "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. Akincigil said 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," Akincigil explained. "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."

The researchers also noted that 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, according to Akincigil. 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," she said.

Akincigil and co-authors Karen A. Zurlo and Stephen Crystal, both from Rutgers' School of Social Work; Mark Olfson, Department of Psychiatry at Columbia University; and Michele Siegel and James T. Walkup from Rutgers' Center for Health Services Research on Pharmacotherapy, Chronic Disease Management and Outcomes, conclude 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," they write. "An increase in the reimbursement of case management services for the treatment of depression also may be effective."

The study was supported by the National Institute of Mental Health and by the Agency for Healthcare Research and Quality through a cooperative agreement for the Center for Research and Education on Mental Health Therapeutics at Rutgers.