Depression Treatment Often Doesn't Go To Those Most In Need

Most Americans who screen positive for depression don't receive treatment, a study finds, while most who did receive treatment don't appear to have the disorder.

"Over the last several years there has been an increase in prescription of antidepressants," says Mark Olfson, professor of psychiatry at the Columbia University Medical Center and lead author of the study, which was published Monday in JAMA Internal Medicine. "In that context, many people assumed that undertreatment of depression is no longer a common problem."

But Olfson found the opposite to be true after analyzing data from Medical Expenditure Panel Surveys in 2012 and 2013 that asked people if they had been screened for depression. Of the 46,417 adults surveyed, 8.4 percent answered in ways that suggested they had depression, but only 28.7 percent of the people who appeared depressed received any treatment for it.

"The findings highlight that there are continuing challenges in aligning depression care with patient needs," Olfson says.

Those in the lowest-income group were five times more likely to appear to have depression compared with those in the highest income group, with 18.2 percent of lowest-income adults screening positive compared to 3.7 percent of the highest-income group. But higher-income people were more likely to get treatment.

People who were female, white, non-Hispanic, had at least a high school education or had health insurance were more likely to get treatment if they were depressed, the study found. People with low incomes, uninsured adults, racial and ethnic minorities and men were less likely to be treated.

Though 8 percent of people surveyed got some form of treatment, most of the people who got treatment probably didn't need it. Only 29.9 percent of the people treated had screened positive for depression; 21.8 percent of them appeared to have serious psychological distress. People with public insurance such as Medicaid and people who were separated, widowed or divorced were most likely to be treated, while uninsured adults, racial and ethnic minorities, and men were least likely.

Antidepressants were far and away the most common treatment, and people with either less serious distress or no depression were more likely to receive them. That could be a problem, Olfson says, because studies have shown that antidepressants are not more effective for patients with mild depression than a placebo.

"Being a little less aggressive in medication in mild depression would be beneficial," he says. "There are simpler forms of psychological interventions that can be adapted for primary care."

Patients with mild depression could first be given nondrug treatments ranging from counseling and exercise to yoga, the researchers say.

And although the study found that those with serious psychological distress are more likely to be treated by psychiatrists instead of general medical professionals, that wasn't the case for older patients, African-Americans, the uninsured or those with less education.

Most people with untreated depression make at least one visit to a primary care doctor annually, and Olfson says those visits could be used to screen people in disadvantaged populations, and ideally offer them mental health treatment at the primary care clinic.

"If you give them a referral to a mental health clinic, they simply won't go if they don't think they have a mental health disorder," he says. "By embedding the services within primary care, it becomes more accessible and less stigmatized."

It's an idea Benjamin Cook, director of the Health Equity Research Lab and an assistant professor at Harvard Medical School, agrees on, but he says increasing access for minorities would require professionals who speak their languages and understand what type of treatment they are open to. Cook was not involved in the study.

"African-Americans and Latinos prefer antidepressants less than whites," Cook says. That might be an underlying reason "not to go for mental health treatment, why they might not stay at treatment for as long."

It can be hard for primary care doctors to find mental health professionals to refer patients to, particularly in rural areas, Olfson says; prescribing antidepressants might be their only option. "Depression really is a serious condition and we're finding that so many Americans aren't receiving care," he adds. "I hope that [this study] brings attention to this situation."

Kaiser Health News is an editorially independent news service supported by the nonpartisan Kaiser Family Foundation.

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