Abstract
Depression is highly prevalent and debilitating in late life. It affected 3.8 million older Americans in 2005, and its prevalence is expected to increase to 6.6 million in 2025. Despite its prevalence and associated negative health outcomes, depression is not diagnosed and treated equally among older Americans. An under-recognition and under-treatment of depression in minority elders exists, which has lead to significant disparities between Whites and non-Whites. These disparities challenge our principles of equality, equity and adequacy and, in their most extreme form, become human rights issues. As a result, eliminating health disparities has become a priority of the US Federal government. Practitioners must address differences in the diagnosis and treatment of depression among clients served. Increased levels of cultural competency and educating clients will help reconcile differences between clinicians and their patients and lead to increased understanding of client needs, while decreasing disparities in depression care and diagnosis.
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Introduction
Depression is highly prevalent and debilitating in late life and predicts a range of negative health outcomes. In 2005, it affected 3.8 million older Americans [1••]. As the baby boom population ages, it is anticipated that the impact of depression on this growing older adult population will increase proportionally. The number of people older than 65 years with psychiatric disorders in the US is projected to increase to about 8.2 million in 2050 [1••], where the increase in depression symptomatology will be most pronounced among older men [1••]. Although progress has been made in characterizing the presentation of late-life depression and in improving treatment, it continues to have detrimental consequences that include family disruption, the worsening of medical illness and disability, and increasing mortality [2, 3]. Moreover, major depression is a leading cause of disability and accounts for more than half the suicides that occur annually [4]. The current health care system serving older adults with mental illness is inadequate and unprepared to meet the upcoming crisis in geriatric mental health [5••].
Moreover, depression is not diagnosed and treated equally among older Americans. Studies indicate that there is continued under-recognition and under-treatment of depression in minority elders [5••, 6••, 7, 8], leading to significant disparities in diagnosis and treatment between Whites and non-Whites. These disparities challenge our principles of equality, equity and adequacy that are at the core of our national identity. As a priority of the US Federal government, efforts to reduce and eliminate mental health disparities are gaining momentum [9].
It is only in the past decade that addressing differences in mental health care has become a national priority. While the term, disparities, is not standardized, it generally implies an inequity or an injustice rather than a simple inequality [10]. The World Health Organization defines disparities as “differences in health that are unnecessary, avoidable, unjust, and unfair” [11]. In a seminal work, the Institute of Medicine defined disparities as “racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention” [12••]. The Joint Center for Political and Economic Studies reported that “the combined costs of health inequalities and premature death in the United States were $1.24 trillion between 2003 and 2006” [13]. Hence, the costs to a society are exorbitant. Not only are lives lost unnecessarily, but disparities often lead to charges of discrimination and, in the extreme, can be considered a human rights issue. To eliminate disparities, research is needed that provides insight into such questions as: How and why do racial and ethnic disparities occur? How do the patient and practitioner contribute to mental healthcare disparities? Do bias, stereotyping, prejudice and poor communication exacerbate these disparities? The studies reviewed in this paper address these and other related questions.
Background on Depression
Depressive symptoms are an important indicator of general well-being and mental health among older adults [14]. Adults who report depressive symptoms often experience higher rates of physical illness, greater functional disability and higher health care resource utilization [15]. Moreover, depressive conditions cause substantial disability, and the costs incurred are substantial as well. In the US alone, in 1990, the cost of depressive conditions was $43.7 billion/year, where, $12.4 billion (28 %) was attributable to direct costs, $7.5 billion (17 %) comprises mortality costs, and $23.8 billion (55 %) was derived from the two morbidity cost categories [16]. These costs have risen dramatically in the recent decade due to the increased rates of diagnosis and the corresponding increased use of anti-depressants. Also, the Surgeon General reported that racial and ethnic minorities bear a greater burden from unmet mental health needs and thus suffer a greater loss to their overall health and productivity [17].
In addition to the emotional strain experienced by those diagnosed with depression, depression predicts a range of negative health outcomes, including total mortality, suicide, and hospitalization, while reducing active life expectancy (at age 70 years) by 6.5 years for men and 4.2 years for women [14]. If untreated or undertreated, depression can significantly diminish quality of life and increase morbidity and mortality among the elderly. Depression also complicates several co-morbid general medical conditions that are common in older populations, such as congestive heart failure, diabetes, and arthritis [17]. Major depression is a prevalent disorder and a major public health concern in the US. In 2008, 11 % of men and 16 % of women aged 65 years and older experienced clinically relevant depressive symptoms [14].
Effective treatment exists. Antidepressant treatment and psychotherapy, particularly in combination, have been shown to be effective in increasing rates of remission. However, trends in the diagnosis and treatment of depression suggest that depression is under-diagnosed and under-treated in older adult members of ethnic and racial minority groups [1••, 2].Understanding these trends is an essential prerequisite to targeting solutions to the affected groups.
Depression and the Elderly
To understand racial and ethnic disparities in depression treatment and diagnosis among the elderly, it is also essential to take into account other demographic characteristics of the population including age differentials, marital status, education, religious preferences, health status, veteran status, and income levels, to name a few. It is in the best interest of policy makers, researchers, administrators and practitioners to understand the characteristics of the elderly population in as much detail as possible, in order to make an accurate assessment and propose appropriately individualized diagnoses and treatments.
In 2008, the proportion of people age 65 years and over with clinically relevant symptoms was higher for people age 85 years and over (18 %) than for people in any of the younger groups (12–15 %) [14]. Also, Sonnenberg, and colleagues [18] conducted a longitudinal study that investigated antidepressant use from 1992 to 2002 in a population-based sample aged 65–85 years. The authors found that antidepressant use increased from 2 % to 6 %. And in the group with major depressive disorder, treatment with antidepressants showed an increase from 15 % to 30 %, where the increase was larger in the older old than in the younger old.
In an older study, Blazer and colleagues [19] studied race as a correlate of medication use in a sample of older adults. They found that, in 1986, a total of 4.6 % of the Whites and 2.3 % of the African Americans in the sample used antidepressants. By 1996, utilization of antidepressants by the Whites in the sample had increased to 14.3 % while, for African Americans, it had increased to 5.0 %. Though antidepressant use had increased for both groups during the 10-year interval, the increase was far smaller for the African American elders.
Summarized below are several more recent studies which, taken together, support the conclusion that mental health disparities are more severe among older adults than in the general population, and are compounded by being at higher risk for misdiagnosis, under-treatment, and more severe depressive symptomatology than Whites. [20]. In treatment, older members of ethnic and racial minority groups are more likely to be given first-generation drugs and fewer prescriptions for similar diagnoses than their White counterparts [20].
Disparities in Depression Care
To understand disparities in the treatment of depression, it is important first to note racial and ethnic differences in rates of diagnosis of depression among older Americans. Akincigil et al. [5••, 6••] found that depression was diagnosed in the elderly with increasing frequency between 1992 and 2006; between the years 1992 – 1995 and 2002 – 2005, the rate rose from 3.2 % to 6.3 %. Trends in antidepressant use increased in these same periods from 7.3 % to 15.3 % among older adults [5••, 6••]. Yet the trend was not consistent among races and ethnicities. Compared with Blacks and Hispanics, Whites were found to have higher rates of diagnosis and treatment with antidepressants.
A secondary analysis of data from the 2005 California Health Interview Survey used a population-based sample of older adults to examine racial and ethnic differences in the prevalence rates of psychological distress and the reported need and use of mental health services [17]. The sample population comprised 16,974 people aged 55 years and older, with 13,974 non-Latino Whites, 719 African Americans, 1,215 Asians, and 1,066 Latinos. The authors found that African Americans, Asians, and Latinos were more likely than Whites to report mental distress (21.2–24.2 % vs. 14.4 %, P < 0.001) [21]. Moreover, all three groups had worse access to mental health services than Whites (African American aOR = 0.64, 95 % CI = 0.43–0.96; Asian aOR = 0.32, CI = 0.16–0.63; Latino aOR = 0.35, CI = 0.17–0.70).
Using a nationally representative sample (N = 8762), Alegria et al. [7] found similar differences between ethnic/racial minority patients and non-Latino Whites with respect to access to and quality of depression treatments. Their results indicated that for those with last year depressive disorder, 63.7 % of Latinos, 68.7 % of Asians, and 58.8 % of African Americans, vs. 40.2 % of non-Latino Whites, did not access any last year mental health treatment (P < 0.001).
In a sample of over 85,000 primary care outpatients residing in the Northeast (Connecticut, New York, Rhode Island, New Hampshire, Massachusetts), Trinh et al. [18, 22] found that minority groups were less likely to be diagnosed with depression than Whites. Of the Whites, 11.36 % were diagnosed with depression; for Asian Americans, African Americans, and Latino Americans, depression diagnosis rates were 6.44 %, 7.55 % and 10.18 %, respectively. Protective factors that may help explain these differences include religiosity and spiritual beliefs, as well as limited cultural understandings between the practitioner and client.
When comparing Whites and non-Whites on depression severity, Gonzalez, Tarraf, Whitfield, and Vega [23] found that major depression chronicity was higher among Mexican Americans, Puerto Ricans and African Americans than among Whites. Secondly, among those meeting 12-month major depression criteria, Vietnamese, Mexican and African Americans were the least likely to receive APA Guideline concordant depression therapy.
Traditional treatment of depression consists of three main modalities: antidepressant use, psychotherapy and the two in combination. A number of studies illustrate that there are disparities in treatment. Whites are more likely to be treated with antidepressants than are Blacks. Another form of treatment that has not received much recognition in the literature is the use of electroconvulsive therapy (ECT). Blacks with depression were less likely to receive ECT than Whites during the 1970s and 1980s. Case et al. [24] examined whether this racial difference in receiving ECT persists. Their results indicated that the disparities persist. Depressed Black inpatients are less likely than Whites to receive ECT; the difference arises almost entirely from the lesser use of ECT in hospitals where it is available.
Yet one complication that impedes identification of disparities in treatment access and quality is the fact that much survey data provide insufficient respondent data by ethnic subgroups [23]. In many large national surveys, the non-White population totals 10 % of the sample, leaving insufficient effect size to draw conclusions from the survey data. Additionally, many surveys do not segregate the race and ethnicity of the respondents in more distinct ways, other than identifying as Black, Hispanic, or Asian. This, too, limits the ability to draw any viable conclusions on non-White populations.
Even so, the studies reviewed support the conclusion that, compared with Whites, African American seniors are under-diagnosed and under-treated for depression. Some plausible explanations exist. To address treatment disparities, the practitioner must understand concerns and preferences of individuals from diverse cultural groups [25, 26]. Perceptions and definitions of depression may vary between African Americans and Whites. By examining beliefs regarding mental health, the practitioner will be better equipped to understand and diagnose a mental health condition.
Cultural Issues
Understanding the concerns and preferences of individuals in diverse cultural groups is critical to their care because unfamiliarity with the patient’s culture can act as a barrier to mental health treatment [27, 29]. In physical healthcare as well as in mental healthcare, patients bring to the healthcare encounter cultural backgrounds, beliefs, practices, and languages that require culturally competent communication to maximize the quality of care they receive [30]. Attunement to cultural differences may be the first step in providing culturally competent care.
Everyone has a culture of origin, which directly affects how one interacts with members of one’s own group and with members of other groups. Cultural background can affect values, beliefs and communication styles. Particularly in the health care setting, the consequences of interaction (e.g., between clinician and patient) can be very serious. Inability to recognize or accept differences between oneself and one’s patient may affect how well instructions are communicated to the patient, or subconsciously affect clinical decision making [30]. The extent to which a patient’s needs are met will depend, at least in part, on the clinician’s awareness of and flexible accommodation to cultural difference [12••]. Investigators have found subtle effects of racial difference on clinician-patient interaction [12••]. Where the race of the physician and patient was the same, visits were longer; in addition, patients in race-concordant visits were more satisfied than patients in race-discordant visits [27, 28]. Hence, culturally competent practice plays a critical role in the understanding and treatment of depression in ethnic minorities. As a result of these findings, in the upcoming publication of the Diagnostic and Statistical Manual of Mental Disorders V (DSM-V) in 2012 substantial revisions are planned to the content of Cultural Formulation; practitioners are asked to operationalize a more thorough evaluation of the socio-cultural context in which the illness (i.e. mental health) experience is embedded [29]. A systematic cultural assessment will be recommended during the encounter between practitioner and client, where the goal is a more inclusive nosology that reminds clinicians and researchers to take culture and context into account during the diagnostic and treatment phases. As a result, conducting a cultural assessment will become good clinical practice. In sum, patient beliefs about mental health must be accurately identified and addressed in the care process [30].
Workforce Issues
In 2008, as the nation’s 78 million baby boomers began to retire, the Institute of Medicine (IOM) issued a report [12••] concluding that the healthcare workforce is not prepared to offer care to the growing number of older patients. The number of physicians, nurses, social workers, occupational therapists and physical therapists in training and practice was projected to be insufficient to meet a growing need of practitioners. Existing disparities in mental health care for older adults – exacerbated by tenuous relationships between minority populations and medical professionals, and by reluctance to seek mental health treatment in particular – may be widened still further by the impending shortage of clinicians. That the need to address these disparities is urgent is evident from reports that shortages are expected as soon as 2020. The Center for Workforce Studies (2012) [32••] highlighted several areas of concern regarding the growing gap between physician supply and demand for services, and made recommendations to improve efficiency within the healthcare system, reconfigure healthcare delivery, and make better use of physicians and other healthcare professionals. The Center further recommended that the Federal Government take an integrated approach to plan for changes in health workforce is [32••].
Changes in the recruitment, admittance and training of individuals in the profession of medicine can be made so society is better prepared to meet the rising needs of mental health care, thus offering some protection for the underserved. For example, medical education accrediting bodies have mandated that the educational experience include training for the care of patients from varied cultural, socioeconomic, and ethnic backgrounds [33]. Cultural competency is included in the curriculum. Better attunement of the medical community to the needs of currently underserved populations could ameliorate the mistrust and miscommunication between patients and physicians.
In response to recognition of depression as a growing public health problem, the Task Force on Community Preventative Services suggests that both home-based and clinic-based depression care management are appropriate and should be encouraged for individuals over 60 years (CDC Promotes Public Health Approach to Address Depression Among Older Adults) [34]. Implementing such changes at the community and public health level might not only improve care and access to care for depressed older African Americans, but also reduce symptom severity and the demand for physicians. More creative use could be made of strengths and resources already present in underserved populations, such as their spirituality and affiliation with African American clergy and church communities, which will be discussed further below. Community-based mental health settings also could do more to develop peer support roles and skills (e.g. by inviting co-facilitation of support groups). Many more individuals might be reached through partnerships of community health, academic institutions and religious institutions.
A Focus on Spirituality
Religion and spirituality can affect health positively. In a number of recent studies, researchers found that everyday religious experiences help people cope better with stress [35, 36]. In a study of 92,500 postmenopausal women, those who reported attending religious services were 27 % less likely to have depressive symptoms than women who did not attend services [37••]. Additionally, spirituality, regardless of one’s faith, is also known to boost mental health. Johnstone and colleagues [38] found that being spiritual decreased a person’s sense of self in a positive manner, which enabled them to feel more connected to the world. Although it is unclear how religious beliefs directly affect mental health, these studies affirm that there is a positive association between the two constructs. As a result, it is recommended that practitioners be aware of the benefits of having a spirituality and become more comfortable broaching the topic of spirituality with the clients they treat.
For example, some African American patients may not believe there is a biological basis to depression and, consequently, may prefer that treatment consist of counseling and prayer. In research by Wittink, Joo, Lewis, and Barg [39] older African Americans claimed that depression was due to a “loss in faith” and faith and spiritual/religious activities could empower an individual by providing strength for healing to occur. Cultural differences in the way depression symptoms are manifested, defined, interpreted and labeled may explain, at least in part, differences in help-seeking behaviors. Blacks are less likely to seek mental health services than their White counterparts [30] and, when they seek services, they attend fewer sessions and are more likely to terminate treatment prematurely [40]. Blacks also are more likely to use informal networks, such as their church, when seeking support, without presenting themselves as depressed. Instead, they may seek friendship and general social connections. These examples illustrate why it is central to patient-centered care that patient beliefs about mental health be accurately identified and addressed in the care process [29]. Shellman and colleagues [41] concurred that there are barriers to the identification and treatment of depression in Black older adults that include the lack of access to quality mental health care, the stigma of mental illness [31], mistrust of mental health providers, and poor provider-client communication.
An approach that might be particularly effective in African American communities might be for providers of medical and mental health care to partner with churches. Gullum [42], for example, has recommended that the church community be the site of intervention and prevention efforts regarding intimate partner violence in the African American community. Though it may not be possible to stretch church resources to add to ongoing programs, low-cost interventions such as timely referral and other aspects of partnering could prove to be just as critical [32••]. Listed below are steps (adapted from Gullum’s recommendations religious institutions) which, if taken, might help to meet some of the needs of African Americans affected by depression.
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Provide education and training to clergy and lay church leaders on depression, to raise awareness and facilitate a meaningful, appropriate response;
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Educate clergy and lay leaders about community resources, such as [fill in a couple of examples];
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Partner with religious institutions to offer support groups facilitated by mental health providers or students in field placements (with appropriate supervision) and supplemented with child care services;
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Offer support groups not only for older adults with depression but also for the adult children who care for them; and
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Provide churches with informative articles for their newsletters or bulletins, to raise awareness of depression and describe the partnership of the church with other community institutions to meet the needs of the faithful.
Joining forces in this fashion, to eliminate barriers such as lack of material resources, failed communication, limited understanding of illness management, and social stigma, could be a start to alleviating racial disparities in mental health care.
Discussion
The literature presented supports the findings that disparities in depression diagnosis and treatment exist. As a consequence of these disparities, health care policy makers, researchers and practitioners must seek knowledge and clinical methods that lessen and ultimately eliminate these disparities. This paper underscores the importance that it is possible to reconcile perspectives between the clinicians and their clients. To reconcile these perspectives, we recommend institutional changes as well as the use of a more client-centered approach during the practitioner’s encounter with the client. The institutional changes pertain to workforce issues and the training and development of more minority practitioners. This will foster more concordant client encounters and minimize the cultural dissonance between client and clinician, leading to more equality and equity in the treatment and diagnosis of depression among elder adults. We also recommend that clinician’s pursue a more open and thorough understanding of the client’s cultural context in the clinical encounter. The importance of the Cultural Formulation will be documented in the DSM V and should act as a guide for all clinicians in the diagnosis and treatment of depression in their clients. For example, depression can be considered a psychological construct that is defined differently by people of different ethnicities. The spiritual beliefs of the client may play a role in how the client presents depressive symptoms as well as how that client may prefer to be treated. Although spirituality and religiosity are relatively new phenomena in the mental health literature, there are findings that support the association between spirituality and mental health. Consequently, it is incumbent upon the practitioner to understand the client’s spiritual life and where possible, use it as a resource in the treatment of depression. Because spiritual beliefs can be a psychological strength to individuals with depression, they should not be ignored in the clinical encounter. Yet, clinicians must be trained to assess a client’s spiritual practice and learn how to discern whether an individual’s spirituality can be used as a positive force in dealing with depressive symptomatology.
Conclusion
The research reviewed here attests to the depth and breadth of the disparities between Whites and racial and ethnic minorities in the diagnosis and treatment of depression. To effectively reduce and ultimately eliminate these disparities, it is recommended that the education and training of mental health professionals be revised to better prepare them for practice in diverse communities. It may be particularly important not only to educate clients about depression but also to invite clinicians and clinicians-in-training to discuss their ambivalence about religion and spirituality so that, when appropriate in treatment, they can reframe spirituality as a strength and a resource. Programs that train mental health professionals also should increase their efforts to recruit minority students. Taking these steps will increase the likelihood that older adults with depression will receive better diagnosis and treatment, thereby reducing or even eliminating disparities in mental health care.
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Zurlo, K.A., Beach, C.M. Racial Disparities in Depression Care among Older Adults: Can the Perspectives of Clinicians and Patients be Reconciled?. Curr Tran Geriatr Gerontol Rep 2, 24–30 (2013). https://doi.org/10.1007/s13670-012-0036-z
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DOI: https://doi.org/10.1007/s13670-012-0036-z