Disparities Found In Depression Care For Elderly AA Population
Mental Health Weekly January 9, 2012
While there have been numerous improvements in depression care over the last 20 years, disparities in depression treatment still exist, particularly for elderly African Americans, igniting a call for universal mental health screening and further research, according to a new study currently online and in the February issue of the American Journal of Public Health (AJPH).
For their study “Racial and Ethnic Disparities in Depression Care in Community-Dwelling Elderly in the United States,” Rutgers researchers culled data from the U.S. Medicare Current Beneficiary Survey 2001-2005, and obtained 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, 65 years and older, researchers found that depression diagnosis rates were 7.2 percent for Hispanics, 6.4 percent for non-Hispanic whites, 4.2 percent for African Americans, and 3.8 percent for others. Among non-Hispanic Whites, 57.9 percent were treated with antidepressants alone, 4.3 percent with psychotherapy only, and 10.8 percent with both antidepressants and psychotherapy, according to the study. Antidepressant use rates were lower among African Americans (52.5 percent) than among non-Hispanic
Whites (68.7 percent), whereas 58 percent of Hispanics used antidepressants.
Rates of psychotherapy use among African Americans (18 percent) and non-Hispanic Whites (15 percent) were not substantially different.
Researchers said they were not surprised by the disparities found in the elderly African American population. “This is something we’re seeing all the time,” Ayse Akincigil, lead author and assistant professor of the School of Social Work at Rutgers University, told MHW. “We’ve seen lots of improvements in depression care over the last 15 or 20 years, but not everyone is benefiting from these improvements equally.”
Akincigil pointed to a previous study she conducted addressing trends in elderly depression and published June 7, 2011 in the Journal of the American Geriatric Society that found a notable increase in depression diagnoses between 1992 and 2005. The proportion of older adults who received a depression diagnosis doubled from 3.2 percent to 6.3 percent with rates increasing substantially across all demographic subgroups.
When researchers adjusted for other characteristics, odds of antidepressant treatment in older adults diagnosed with depression were 86 percent greater for women, 53 percent greater for men, 89 percent greater for whites, 13 percent greater for African Americans.“Older people are depressed and their depression [goes] unrecognized — that’s the first barrier to treatment,” said Akincigil.
In the AJPH study researchers set out to determine why depression often goes undetected and undiagnosed in the elderly, particularly in the African American population, said Akincigil. “Is it because they live in an area where the services are limited? Are they poorer? Are Caucasians more affluent? Is that a barrier?” she noted. The differences in the diagnosis rates for elderly African Americans persisted despite adjusting for education, personal income and insurance coverage, said Akincigil. Cultural reasons, communication challenges between physicians and patients and stigma could be contributing factors, she said. They might feel they can handle the depression themselves or [address it] by talking to their minister,” she said.
Stigma still remains an issue in the help-seeking behaviors of African Americans, along with their attitudes toward depression, Akincigil said. Further research is needed, she said. “We need to figure out what drives the differences,” she said.
The study found that elderly African Americans may not feel confident in describing their symptoms to a primary care physician, she noted. “They may have a hard time speaking up,” she said. This may also be a potential area for further investigation, she said.
“It is well-known that minorities with mental health conditions are underserved in comparison to whites,” Michael B. Friedman, adjunct associate professor at the Columbia University Schools of Social Work and Public Health, who was not involved with the study, told MHW. “This study adds evidence regarding that problem.”
Added Friedman, “There are many reasons why minorities are underserved including inadequate health care coverage, language barriers, cultural preferences regarding pathways to help, maldistribution of public mental health services, and more. All of these are issues that could be better addressed at the federal, state, and local levels.”
Solutions include attention to workforce issues, added Friedman. “How do you get a workforce that is linguistically, culturally and clinically competent?” he noted. “These are common issues,” said Friedman, founder and honorary chair of the Geriatric Mental Health Alliance of New York.
According to researchers, “vigorous” clinical and public health initiatives are needed to address this persisting disparity in depression care. “Universal screening for depression is key and more awareness,” said Akincigil. That’s the first step; you can’t bring them into care if they’re not identified,” she said.
Other initiatives such as public education to help reduce the problem of stigma might help, she added. If for example, minorities tend to turn to pastors or others in the community for help, then perhaps those in the community could be trained in offering them referrals or more assistance, Akincigil said. •