Depression in African Americans: Breaking barriers to detection and treatment

,

Applied Evidence

Depression in African Americans: Breaking barriers to detection and treatment

J Fam Pract. 2006 January;55(1):30-39

By

Amar K. Das, MD, PhD

Community-based studies tend to ignore high-risk groups of African Americans.

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References

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Practice recommendations

When evaluating African Americans for depression, look for somatic and neurovegetative symptoms rather than mood or cognitive symptoms (C).
Education can help patients better tolerate drug regimens and improve chances for treatment success (C).
Practice improvement efforts can improve health outcomes in depressed African Americans (B).

African Americans depend on quality mental health services in primary care more so than whites, since they are more likely to seek care in this setting. However, accumulating evidence shows that African Americans in primary care settings face disparity in recognition and treatment of depression (see Race and mental health treatment: the divide).^1-5 Until now, the specific factors leading to this disparity have not been well described.¹⁶

In this article—a systematic review of studies on the evaluation and treatment of depression in African American patients—we draw attention to factors regarding patients, physicians, and clinical settings that raise barriers to diagnosis and treatment. We also recommend strategies to break through these barriers.

Race and mental health treatment: the divide

Racial disparity in mental health treatment is a difference across racial groups not justified by underlying differences in mental health status or patient treatment preferences. The reasons are numerous. Compared with whites, for example, African Americans are more likely to be poor, uninsured, or have restrictive insurance policies,^6,7 and to have limited means of transportation to reach health services.⁸ But even after controlling for differences in insurance and socioeconomic status, African Americans are less likely than whites to use outpatient mental health services,^9,10 and they therefore face disparities in quality of care.^11,12 Thus, economic factors and illness severity do not fully account for the observed racial differences in the rate and quality of treatment of mental disorders.

Racial disparities may also emerge in the decisions physicians make in caring for patients. In several clinical contexts, members of minorities have received less and inferior care than white patients.^13,14 In one epidemiologic study, African Americans were reported to receive less access to mental health care and to have greater unmet needs for mental health care than whites.¹¹ Because differences in access to care can have consequences for health outcomes, reducing health care disparities is a widely shared goal of clinical and public health care policy.¹⁵

Assumptions that mask disparities

Disparities may not be apparent to healthcare providers in part because community-based epidemiologic studies report that African Americans have a lower rate of major depression than whites.^5,17-19 In primary care settings specifically, the prevalence of major depression among African Americans appears to be lower than for white or Hispanic Americans, mirroring rates in national and community studies.²⁰ Explanations for this relatively low prevalence of depression have included attributes of the African American experience, such as strong religious beliefs and community ties.

Moreover, according to analyses of data from the National Comorbidity Study, which included an examination of attitudes toward mental health services, African Americans with major depression are more likely to report that they would “definitely go” for mental health services than would whites.²¹

High-risk populations overlooked. Community-based studies, however, do not fully capture the mental health needs of African Americans, a large number of whom are in high-risk populations excluded from community epidemiologic studies of mental disorders. Studies of these populations show high rates of major depression and other mental disorders, due to factors including alcohol and substance use disorders, poor physical health, and poverty and homelessness.

FAST TRACK

One study found that physician characteristics influenced diagnosis, but patient attributes did not

An unsettling irony. For emotional distress, African Americans are more likely to seek help from primary care clinicians than from specialty mental health providers.^22-24 However, in primary care, depression in African Americans is less likely to be detected than it is in whites.³

In a nationally representative sample, African Americans have been found less likely than whites to receive effective care for depression in primary care.^12,25,26 In a study of Medicaid recipients who had been diagnosed with major depression, African Americans less often received antidepressant medications than did whites.²⁷ Such disparities in pharmacologic treatments were also found in another study of African American patients in primary care, using data from the National Ambulatory Medical Care Surveys.²⁴

Search methods

Data sources

We systematically searched for and retrieved articles in Medline (January 1966 to December 2004) using the MeSH (medical subject heading) terms African Americans and depressive disorder along with the MesH terms adult or adolescent. We refined our search results using the MeSH terms diagnosis, comorbidity, physician-patient relations, patient satisfaction, and patient acceptance of health care to focus on patient and physician factors.