Antibiotics, eat your hearts out.
Today, antidepressants are the most commonly prescribed class of medications in the United States–and that’s even without Lipitor playing on their team.
Since the late 80’s, usage of antidepressants has soared–so much so that a report by the CDC’s National Center for Health Statistics claims the rate of antidepressant use in the U.S. has increased nearly 400% since 1988. But to simply state that antidepressant use has grown by leaps and bounds tells only part of the story.
Olfson and Marcus, in “National patterns in antidepressant medication treatment,” found, in studying antidepressant treatment in the U.S. from 1996-2005, that the rate of antidepressant treatment increased overall–but not for specific groups:
Significant increases in antidepressant use were evident across all sociodemographic groups examined, except African-Americans, who had comparatively low rates of use in both years. Although antidepressant treatment increased for Hispanics, it remained comparatively low.
Apparently some people are less a part of the antidepressant craze than others. And those results show up again and again. Blazer et al studied the more targeted group of the depressed elderly. In a 10-year study with interviews conducted every year, they analyzed a sample of 4,162 community residents 65 years old and older.
The researchers found–no surprise–increased antidepressant use overall, but once again there were significant differences between white and African-American use. “In 1986–1987 whites were twice as likely to take antidepressants as African-Americans,” they write,
“and this variance increased to nearly a threefold difference by 1996–1997.”
The facts speak for themselves–there’s no arguing against them: African-Americans are far, far less likely than whites to be on the antidepressant bandwagon. But those are just the facts, ma’am. Don’t we have some obligation to investigate why antidepressant use lags behind so for African-Americans? Really, it behooves us to ask.
At first glance one might guess that it’s part of a systemic system of racial inequality that this country hasn’t truly recovered from since its infancy–and it’s likely that plays a role somewhere in this complicated issue.
But in fact the situation is more complex than it at first seems, as a number of factors play a role in this discrepancy, and they don’t all boil down to inferior treatment of minorities on the part of the medical system.
Sociologist Dr. Clifford Broman found that, contrary to how educated whites advocate for their own treatment, Blacks with higher levels of education were less likely to seek out mental health services than their white counterparts to begin with, thus proscribing treatment with antidepressants from the get-go. Writes Broman:
Past research has indicated [that] people with higher education levels are more likely to seek out and receive mental health services. While that may be true for whites, it appears the opposite is true for young adult blacks.
If you’re depressed, but won’t go see a doctor, well, seems fairly self-evident you won’t be treated with a course of antidepressants, doesn’t it? It’s a logistical problem.
The author’s theories about why Blacks make less use of mental health services run from greater concern on their parts about stigma associated with mental illness, to a more traditional reliance on family, religious and social communities for support, in place of mental health professionals, to lack of cultural sensitivity among treaters–motifs that recur throughout a discussion of gaps in antidepressant treatment between whites and minorities.
And, given how inflammatory the studies about unequal antidepressant use among races could be, it pays to look at a few more pieces of research that call into question the assumption underlying the upsetting initial statistics.
For example, in “Race, quality of depression care, and recovery from major depression in a primary care setting,” Rollman et al point out a critical flaw in most of the studies that tout discrepancy in treatment. Just as another study, run by Oxman et al, too, claims, the researchers assert that, by patient choice, the majority of depressive episodes are treated in primary care practices. Thus many of the studies touting inequality in treatment failed to examine treatment at the primary care level, where most African Americans (and most Americans in general) get treatment–and, surprisingly–often failed to adjust for socioeconomic level. Here’s the problem with the previous research:
While other studies have found physicians less likely to identify African-American patients as depressed or to initiate antidepressant pharmacotherapy with them compared to Caucasian patients these studies were not conducted in the primary care settings where a significant number of depressed patients- particularly African-Americans – are treated [italics mine].
So, in a word, the studies are being conducted in the wrong setting. To analyze psychiatrists’ treatment patterns of minorities is to miss the boat and yields misleading information about racial discrepancies.
Aah–We’ve found the first chink in the armor–and now we need to go back and examine what happens in the usual treatment setting. Take 2.
Enter Miranda and Cooper, who studied 1498 depressed patients seeking treatment from primary care physicians. And what should they find, but that there were no ethnic differences in patient reports of what their primary care provider recommended as depression treatments. Fascinating, no? Move your analysis back to the place where most treatment happens–and it appears you lose the most concerning statistics.
But the story goes on. For, sure enough, among those for whom these treatments were recommended, the percentages of Hispanic and Black patients taking antidepressants were still lower than the percentage of white patients.
What gives? Recommendations for meds are the same among racial groups in primary care settings–but Blacks still lag behind in antidepressant use. What happens?
Well, according to the study, “Latinos . . .and African-Americans . . .had less odds of taking antidepressant medications than did white patients” [italics mine].
Now that’s telling a whole new story, one that must ask us to re-evaluate some of the initial data.
The results were duplicated in another study, this one entitled “Disparities in the adequacy of depression treatment in the United States”–and it adds another layer. Harman et al found that, should the African-Americans or Hispanics actually go ahead and fill their prescriptions, indicating an engagement with treatment, then there was “no difference in the probability of subsequently receiving adequate treatment” [italics mine].
Pretty powerful. Means if the minorities simply agreed to fill the scripts–scripts that were prescribed to them in the same percentages as whites–then differences in follow-up treatment evened out–minorities and whites were provided with the same types of treatments plans. It’s a very different look at who’s holding the cards when it comes to differential antidepressant use.
But we’re left with this question: if Blacks and Hispanics went to the doctor complaining of depressive symptoms, and received prescriptions for antidepressants–what prevented them from following through on the recommended treatment?
In a fascinating study entitled “The acceptability of treatment for depression among African-American, Hispanic, and White primary care patients,” the authors find that, although primary care physicians did, in fact, recommend antidepressants equally to Blacks and to whites, thus confirming the previous study’s findings, factors specific to culture prevented those recommendations from being carried through.
Turns out that the odds of finding antidepressant medication acceptable at all were significantly lower for African-Americans and Hispanics than for whites–and so the two minority groups simply didn’t follow the doctors’ recommendations–and never stopped by their local CVS. The prescriptions might well be in their recycling bins, for all we know.
According to the National Mental Health Association survey on attitudes about depression, close to 30% of African-Americans said they would handle depression themselves, should they suffer from it, while an additional 20% said they’d seek help from family or friends. It’s not a culture that turns to a pill at the first sign of distress. Finally, only 1/3 said they’d take antidepressants for depression, if prescribed by a doctor. It isn’t the treater creating a division; it’s the treated.
Beyond that, the study found two more reasons for lack of follow-through on taking the prescribed antidepressants. First, African-Americans were the least likely of all groups studied to believe that medications are effective in treating depression (whites are the most likely). Second, Blacks and Hispanics were more likely than white persons to believe that antidepressant medications are addictive.
If you factor in these three realities, it’s no surprise that Blacks fail to fill their prescriptions–and thus take significantly fewer antidepressants than their white counterparts. No surprise–and not, apparently, a question of racist treatment.
When compared to whites, African-Americans, Latinos, and Asian/Pacific Islanders all preferred counseling over medications. Down again goes the percentage treated with antidepressants.
In a study published as “Ethnicity and preferences for depression treatment,” researchers utilized the Internet to study 78,753 depressed adults over 40 months. Again when compared with whites, African-Americans were less likely to believe antidepressants were effective–and the explanation for this arrives: Blacks are simply much less likely to believe that depression is biologically based. If there’s no biological component, it makes good sense not to take a pill claiming to change your biochemistry.
African Americans were also much more likely than whites to believe that prayer was of benefit, perhaps to the exclusion of pharmaceuticals. In fact, in the National Mental Health Association survey, almost two-thirds said that prayer will successfully treat depression “almost all of the time” or “some of the time.”
Just so we’ve all got it–in primary care facilities, with socio-economic realities factored in, Blacks are just as likely as whites to receive prescriptions for antidepressants from the physician. But they are nowhere near as likely to follow through on that doctor recommendation, and actually take the meds. No wonder those early studies found African-American antidepressant use lagging behind–they’re using the backs of the prescriptions to explain long division to their fifth-graders, yet again.
Surely other systemic problems remain and need to be worked through. In “Patient race and psychotropic prescribing during medical encounters,” the authors found, after analyzing audiotaped sessions between patients and primary care providers, that the physician’s communication style influences both the diagnosis and the decision to treat. They believed that a tendency existed on the part of the physician to minimize emotional expression by African-Americans relative to whites. This, of course, did yield a lower rate of antidepressant prescriptions.
Determining why African-Americans take so many fewer antidepressants relative to whites is, indeed, a complex issue, and, as the above study notes, it’s possible that lack of understanding between the races–a centuries-long problem–contributes to the dilemma. That also makes it exciting data to have the press run with–it becomes not just a question of medication prescriptions, but a metaphor for societal inequalities.
But what I find so fascinating is an alternative way of viewing it, one that isn’t, actually, a condemnation of society. It’s not that African-Americans are being kept away drug treatments that are all the rage for white patients. There’s another option:
Isn’t it just possible that they themselves have opted out of the antidepressant craze–and aren’t really all that deprived as a result?
Blazer G, et al. Marked differences in antidepressant use by race in an elderly community sample: 1986–1996. American Journal of Psychiatry 2000; 157(7):1089-1094.
Broman C. Race differences in the receipt of mental health services among young adults. Psychological Services 2012; 9(1): 38-48.
Cooper L, et al. The acceptability of treatment for depression among African-American, Hispanic, and White primary care patients. Medical Care 2003; 41(4):479-489.
Givens JL, et al. Ethnicity and preferences for depression treatment. General Hospital Psychiatry 2007; 29(3):182-191.
Harman JS, Edlund MJ, Fortney JC. Disparities in the adequacy of depression treatment in the United States. Psychiatric Services 2004; 55(12):1379-1385.
Lin H, Erickson S, Balkrishnan R. Physician Prescribing Patterns of Innovative Antidepressants in the United States: The Case of MDD Patients 1993-2007. The International Journal of Psychiatry in Medicine 2011; 42(4):353-368.
Miranda J, Cooper LA. Disparities in care for depression among primary care patients. Journal of General Internal Medicine 2004; 19(2):120-126.
Olson M, Marcus SC. National patterns in antidepressant medication treatment. Archives of General Psychiatry 2009; 66(8):848-856.
Oxman TE, Dietrich AJ, Schulberg HC. Evidence-based models of integrated management of depression in primary care. Psychiatric Clinics of North America 2005; 28(4):1061-77.
Rollman BL, et al. Race, quality of depression care, and recovery from major depression in a primary care setting. General Hospital Psychiatry 2002; 24(6):381-90.
Sleath B, Svarstad B, Roter D. Patient race and psychotropic prescribing during medical encounters. Patient Education and Counseling 1998; 34(3):227-38.