by Joye C. Anestis
We have spent a considerable amount of time here at PBB discussing the treatment of major depression. If you're a regular reader, you know that effective depression treatments are well-documented, and consumers have a variety of choices when seeking out evidence-based treatments (current ESTs for depression are cognitive-behavioral therapy, CBASP, interpersonal psychotherapy, and antidepressants). Despite the success in treating depression, only a handful of depressed individuals actually receive help (Kessler et al., 2003; Young et al., 2001). This issue is at the heart of PBB, where we try to raise public awareness of the effective treatments available in an effort to help end some suffering.
A new study in Archives of General Psychiatry aimed to further understand the overall underutilization of depression treatment in two ways: separating treatment into either pharmacotherapy and psychotherapy (previous studies have only looked at treatments lumped together into one group) and examining underutilization in specific racial/ethnic groups. The authors, Hector Gonzalez and colleagues, utilized the National Institute of Mental Health Collaborative Psychiatric Epidemiology Surveys for their investigation. This database consists on noninstitutionalized individuals who were administered the World Mental Health Composite International Diagnostic Interview. Among the information gleaned from this interview is a 12-month diagnosis of major depressive episode. The authors were able to examine 5 ethnic/racial groups within this database: Mexican, Puerto Rican, Caribbean black, African American, and non-Latino white (race/ethnicity was self-identified). As mentioned before, the authors looked at two depression care outcomes: pharmacotherapy (determined by self-report and pill bottle inventories) and psychotherapy (self-report).
An interesting aspect of this study was the authors' investigation of the adequacy of treatment. Following the American Psychiatric Association's Practice Guideline for the Treatment of Patients with Major Depressive Disorder (2000), adequate pharmacotherapy use was defined as antidepressant use for at least 60 days with supervision by a prescribing clinician for at least 4 visits in the past year. Adequate psychotherapy was operationalized as at least 4 visits to a mental health professional in the past year lasting on average for at least 30 minutes (I don't know about you but that seems like a very generous definition of adequate therapy!). It is important to point out here that the authors did not further specify depression treatment (i.e., all psychotherapies were lumped together) and so were unable to examine use of ESTs versus other treatments.
Still the results are telling about the state of mental health care in the United States, and especially the racial/ethnic disparities that exist. Of those meeting 12-month major depressive episode criteria, only 50.76% (standard error = 2.76) received any depression therapy and only 21.28% (standard error = 1.60) received adequate depression treatment! I find this result completely tragic...only about half of the depressed people in this country received any kind of treatment and a little more than a fifth received "adequate" care based on, in my opinion, a very generous definition (for psychotherapy, at least 4 visits of at least 30 minutes in length)!
Furthermore, while none of the 5 racial/ethnic groups examined differed significantly in the overall severity of depression, marked differences in treatment use did emerge. Specifically, African Americans and Mexican Americans were the least likely to receive depression care, especially adequate care. Pharmacotherapy use overall and adequate pharmacotherapy treatment was lowest for Mexican American, Caribbean black, and African American individuals. While overall psychotherapy use was higher than pharmacotherapy use, again Mexican American, Caribbean black, and African American individuals reported the lowest use. Interestingly, the rate of adequate treatment was higher for psychotherapy than pharmacotherapy. In terms of depression prevalence, Puerto Rican individuals had the highest 12 month major depression prevalence, a finding consistent with previous studies (Alegria et al., 2007; Vega et al., 2009), but these individuals had treatment rates consistent with (and sometimes higher than) non-Latino whites. The authors reported some interesting conclusions about health insurance coverage, an important factor they argued could contribute greatly to ethnic/racial minority groups having access to mental health care. They found that health insurance coverage was associated with higher depression care but not with adequate care...so health insurance does increase access to care but, contrary to what I would expect and hope, it does not ensure better care. Importantly, a lack of health insurance coverage partially explained the depression care disparities for Mexican American individuals but not for African American individuals, meaning that other factors influence access to care in for this population. Other factors that have been suggested, but not investigated in this study, include perceived discrimination and a perception of bias in the health care system.
Over the past few decades, there has been a strong movement within clinical psychology to change the image of mental health treatment away from something just done by rich, White people (this stereotype was perpetuated during the heyday of Freudian psychoanalysis when only a small number of people could afford the years-long treatment advocated). Many people are working to increase access to mental health care to all individuals in need. The findings reported here by Gonzalez and colleagues indicate that there is still much work to be done, not only with ethnic/racial minority groups (and especially African Americans and Mexican Americans), but with the population as a whole. Effective (and often fast-acting) treatments exist...we've just got to let the world know about them!
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.
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