Major Finding: African Americans were 60% less likely to receive pharmacotherapy and 40% less likely to receive psychotherapy than were non-Latino whites with depression. The results for receiving “any depression therapy” were 30% for Caribbean blacks vs. 54% for non-Latino whites
Data Source: Nationally representative sample of 15,762 adults in the Collaborative Psychiatric Epidemiology Surveys. Nationally representative sample of 6,504 adolescents in the National Longitudinal Study of Adolescent Health.
Disclosures: None of the investigators in either study reported relevant conflicts.
Two recent studies highlight some surprising racial and ethnic disparities in the origin of depression and its treatment among adults and adolescents in the United States.
For example, in one of the studies, the investigators identified a large gap between the percentage of Caribbean blacks and non-Latino whites who met 12-month major depressive episode criteria and received “any depression therapy.”
In another study, researchers were able to identify a variety of risk factors for depression in European American adolescents. However, a single demographic variable emerged as a dominant predictor of depression in African Americans.
In the first study, investigators analyzed survey data from three nationally representative samples of Americans aged 18 years and older, totaling 15,762 individuals. Hector M. González, Ph.D., of Wayne State University, Detroit, and his colleagues, determined that 8.3% of those surveyed met DSM-IV criteria for major depression during the previous 12 months. After controlling for sex, sample sizes, and other factors, no significant differences were found among African Americans, Mexican Americans, Puerto Ricans, Caribbean blacks, and non-Latino whites in the rate of depression (Arch. Gen. Psychiatry 2010;67:37-46).
After correcting for age, sex, education, health insurance, and household income, African Americans were 60% less likely to receive pharmacotherapy and 40% less likely to receive psychotherapy than were non-Latino whites. The other groups did not differ significantly on that measure.
But receiving some therapy does not imply that a patient receives adequate therapy. The survey data allowed investigators to estimate how many of people with depression were receiving adequate therapy, that is, therapy concordant with published treatment guidelines. Overall, only 11% of the depressed individuals received guideline-concordant pharmacotherapy, and only 19% received guideline-concordant psychotherapy.
Caribbean blacks fared worst on this measure, being 95% less likely to receive guideline-concordant pharmacotherapy than were non-Latino whites. Whether an individual had health insurance was another significant independent predictor of depression treatment.
In the other study, Dr. Benjamin W. Van Voorhees of the University of Chicago and his colleagues analyzed data from a survey conducted in the mid 1990s of a national representative sample of 6,504 adolescents in grades 7-12. As judged by a five-item version of the Centers for Epidemiological Study-Depréssion (CES-D) scale, the investigators determined that African Americans had a slightly higher incidence of depressive episodes than did European Americans (11.5% vs. 8.6%) (J. Natl. Med. Assoc. 2009;101:1255-67).
In a multiple exposure model that corrected for a large number of variables, the demographic variable “neither parent finished high school” emerged as overwhelmingly associated with depression in African Americans, conferring a 21-fold increase in relative risk. Other significant factors for African Americans were “rates survival until age 35 unlikely,” (relative risk 2.62), “got headaches over the previous year,” (relative risk 3.34), and “reports trouble getting along with your teachers,” (relative risk 2.69).
For European Americans, seven factors emerged as significant in the multiple exposure model. The one with the highest relative risk was “friend attempted suicide,” (relative risk 5.16).
The investigators concluded that “the typical framework for risk that focuses heavily on affect and cognition may have been heavily influenced by the predominance of European American youth in previous studies,” and that African Americans might have “unmeasured resiliency factors that protect them in the face of factors [that] increase the risk of episodes among European Americans.
My Take
Low Treatment Rates Dismaying
Both of these studies underscore the importance of making care accessible in different communities, perhaps using different strategies. They also may help us identify factors that can be targeted in treatment for various populations.
The article by Dr. Gonzalez and colleagues was intriguing—and dismaying. The definitions they used for pharmacotherapy gave a tremendous amount of latitude for calling a treatment “guideline-concordant.” It suggests that things are bad now, but they're probably even worse than they appear to be.
Although we've known for decades that depression is often not treated, and even when it is treated, even in academic centers, it's not treated well, these results show just how staggeringly low treatment rates are.