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Despite improvements to diagnostic tools and therapies in the twolast decades, significant disparities in the diagnosis andtreatment of depression remain, according to Rutgers research published online by theAmerican Journal of Public Health (print, February 2012). In the study "Racial and Ethnic Disparities in Depression Care inCommunity-Dwelling Elderly in the United States," lead author AyseAkincigil, an assistant professor in Rutgers' School of SocialWork, and colleagues found that African Americans weresignificantly less likely to receive a depression diagnosis from ahealth 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 toaddress this persisting disparity in care," she said. Depression is a significant public health problem for olderAmericans - about 6.6 percent of elderly Americans experience anepisode of major depression each year. "If untreated orundertreated, depression can significantly diminish quality oflife," Akincigil said. In addition, depression can complicate suchmedical conditions commonly found in older populations ascongestive heart failure , diabetes and arthritis . For their study, Rutgers researchers culled data from the U.S. Medicare Current Beneficiary Survey, 2001-2005 obtaining information onhealth care use and costs, health status, medical and prescriptiondrug insurance coverage, access to care and use of services. Basedon a national survey of 33,708 Medicare beneficiaries, depressiondiagnosis rates were 6.4 percent for non-Hispanic whites, 4.2percent for African Americans, 7.2 percent for Hispanics and 3.8percent for others. The heterogeneity of Hispanics makes itdifficult to determine why they are undertreated and theirtreatment preferences, Akincigil said. "Are there cultural differences or systemic differences regardinghealth care quality and access for treatment of depression?"Akincigil asked. "If African Americans prefer psychotherapy overdrugs, then accessing therapists for treatment in poorerneighborhoods is a lot more difficult than it is for whites, whogenerally have higher incomes and live in neighborhoods more likelyfor therapists and doctors to be located. "Whites use more antidepressants than African Americans. We presumethey have better access to doctors and pharmacies, and more moneyto spend on drugs." The investigation focused on whether there are racial/ethnicdifferences in the rate of diagnosis of depression among theelderly, controlling for sociodemographic characteristics anddepression symptoms (depressed mood, anhedonia) reported on atwo-item screener, and also in treatment provided to thosediagnosed with depression by a health care provider. Akincigil saidthere is evidence that help-seeking patterns differ byrace/ethnicity, contributing to the gap in depression diagnosisrates. Stigma, patient attitudes and knowledge also may vary byrace and ethnicity. "African Americans might turn to their pastors or lay counselors inthe absence of psychotherapists," she said. "Low-income AfricanAmericans who were engaged in psychotherapy reported that stigma,dysfunctional coping behavior, shame and denial could be reasonssome African Americans do not seek professional help." The nature of the patient-physician relationship also mightcontribute to disparities in depression diagnosis rates. "AfricanAmericans reported greater distrust of physicians and poorerpatient-physician communication than do white patients," Akincigilexplained. "Communication difficulties may contribute to lowerrates of clinical detection of depression because the diagnosis ofdepression depends to a considerable degree on communication ofsubjective distress." The researchers also noted that racial and ethnic differences inthe clinical presentation of depression may further explain thelower rates of depression detection among African-Americanpatients. Financial factors may also play a role in the detection rates,according to Akincigil. Among Medicare beneficiaries, AfricanAmericans are substantially less likely than non-Hispanic whites tohave private supplemental insurance that covers charges larger thanstandard Medicare-approved amounts. "Differences in providerreimbursement may favor increased clinical detection of depressionin white patient groups if higher payment rates result in longervisits," she said. Akincigil and co-authors Karen A. Zurlo and Stephen Crystal, bothfrom Rutgers' School of Social Work; Mark Olfson, Department ofPsychiatry at Columbia University; and Michele Siegel and James T.Walkup from Rutgers' Center for Health Services Research onPharmacotherapy, Chronic Disease Management and Outcomes, concludethat "efforts are needed to reduce the burden of undetected anduntreated depression and to identify the barriers that generatedisparities in detection and treatment." "Promising approaches include providing universal depressionscreening and ensuring access to care in low-income and minorityneighborhoods," they write. "An increase in the reimbursement ofcase management services for the treatment of depression also maybe effective." The study was supported by the National Institute of Mental Healthand by the Agency for Healthcare Research and Quality through acooperative agreement for the Center for Research and Education onMental Health Therapeutics at Rutgers. Additional References Citations. 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