Less Depression Treatment in Older Men, African Americans, Latinos

Older men, African Americans and Latinos with clinical depression reported significantly lower rates of treatment than other participants surveyed in a national study led by UCLA Neuropsychiatric Institute researchers. Overall, fewer than one in three depressed older adults studied had received potentially effective treatment for depression in the last three months. The survey is part of the largest study of depression treatment in older adults published to date.

Writing in the April edition of the peer-reviewed Journal of the American Geriatrics Society, the researchers also found that while a majority of study participants indicated a preference for depression counseling to antidepressant medication, antidepressants were more commonly used in the clinics studied.

"Our findings suggest that we are still not meeting the medical needs of millions of depressed older adults," said Dr. Jurgen Un"¢tzer, an associate professor of psychiatry at the David Geffen School of Medicine at UCLA who directed the study coordinating center at the UCLA Neuropsychiatric Institute. "The challenge in treating late-life depression clearly goes beyond writing an initial antidepressant prescription. Considerable effort is needed to monitor outcomes and match treatments to the clinical needs and preferences of individual patients over time."

The study:

A total of 1,801 depressed adults age 60 and over were surveyed at 18 primary care clinics in California, Indiana, North Carolina, Texas and Washington. Researchers gathered an array of sociodemographic information, assessed the severity of depression symptoms, and gathered data on previous depression treatments and chronic medical problems.

The researchers reported that 83 percent of the depressed study participants reported depression symptoms lasting two or more years, and 71 percent reported two or more prior bouts of major depression. About 65 percent reported any past depression treatment, 46 percent reported depression treatment in the past three months, and only 29 percent reported potentially effective depression treatment in the past three months.

Most of the treatments involved newer antidepressants such as selective serontonin reuptake inhibitors, which constituted 78 percent of the antidepressants prescribed. A total of 51 percent of participants indicated a preference for counseling or psychotherapy over antidepressant medications, but only 8 percent had received such treatment in the past three months, and only 1 percent reported four or more sessions of counseling.

The study found that men were consistently less likely to report lifetime or recent depression treatment than women.

"Older men may have different attitudes from those of older women, such as a need to 'handle problems themselves' and not asking for help, and some attach more stigma to depression," Un"¢tzer said. "Although most research on gender differences in quality of care for chronic medical disorders find that men receive better care, depression may be one condition for which men receive lower quality care than women."

African Americans and Latinos surveyed also reported substantially lower rates of depression care. The survey showed 68.2 percent of White participants reported any lifetime depression care, while just 53.6 percent of African American and 55.7 percent of Latinos reported such care.

"Older adults from these minority groups may experience special barriers to depression care, including financial challenges, differences in symptoms, mistrust of providers, fear of stigma, and limited access to mental health professionals, particularly providers with minority backgrounds," Un"¢tzer noted. "Special efforts should be directed to improving access to culturally competent depression care for depressed older Latinos and African Americans."

Depression primer:Of the 31 million Americans ages 65 and older, nearly 5 million suffer symptoms of depression. Up to 10 percent of older adults who visit a primary care physician suffer from a condition called major depression. This condition becomes chronic or recurrent for up to 50 percent of those affected, particularly in older adults with poor physical health.

Functional impairment and diminished quality of life cause tremendous suffering for depression patients and their families, as well as increased health care costs and deaths from medical illnesses and suicide. For example, older white men make up 10 percent of the nation's population but account for 33 percent of all suicides.

While late life depression can be treated successfully with antidepressant medications such as Prozac or with specific types of psychotherapy, few older adults receive appropriate treatment from mental health providers or primary care physicians.

A number of factors hamper effective treatment. Many older adults and their family members view depression as a "normal" part of the aging process and not a medical illness that can or should be treated. In addition, primary care providers are busy looking after many other medical problems and often don't have time in a busy 10- to 15-minute visit to properly diagnose or treat depression. Even when depression is diagnosed and patients are started on treatments, it is difficult for primary care physicians to provide adequate monitoring and follow-up, and many depressed older adults drop out of treatment too early.

The survey was conducted as part of an $11 million study of a new model care program titled Improving Mood -- Promoting Access to Collaborative Treatment (IMPACT). The program provides patients with a depression care manager, such as a nurse or psychologist, who works closely with the patients' regular primary care provider. Study investigators reported in the December edition of the Journal of the American Medical Association (JAMA) that the IMPACT treatment program more than doubled the effectiveness of usual care for depression.

Study participants:The John A. Hartford Foundation, California Healthcare Foundation, Hogg Foundation and Robert Wood Johnson Foundation funded the IMPACT study.

The study was coordinated at the UCLA Neuropsychiatric Institute. Participating study sites include Duke University, Durham, N.C.; The South Texas Veterans Health Care System, The Central Texas Veterans Health Care System, and The San Antonio Preventive and Diagnostic Medicine Clinic in conjunction with the University of Texas Health Science Center at San Antonio; Indiana University School of Medicine and Health and Hospital Corporation of Marion County, Indianapolis; Group Health Cooperative of Puget Sound in cooperation with the University of Washington, Seattle; Kaiser Permanente of Northern California, Oakland and Hayward, Calif.; Kaiser Permanente of Southern California, San Diego; and Desert Medical Group, Palm Springs, Calif.

The UCLA Neuropsychiatric Institute is an interdisciplinary research and education institute devoted to the understanding of complex human behavior, including the genetic, biological, behavioral and sociocultural underpinnings of normal behavior, and the causes and consequences of neuropsychiatric disorders. In addition to conducting fundamental research, the institute faculty seeks to develop effective treatments for neurological and psychiatric disorders, improve access to mental health services, and shape national health policy regarding neuropsychiatric disorders.

Online resources:

* UCLA Neuropsychiatric Institute: www.npi.ucla.edu.* IMPACT Project: www.impact.ucla.edu* Journal of the American Medical Association: jama.ama-assn.org/* The John A. Hartford Foundation: www.jhartfound.org* The California HealthCare Foundation: www.chcf.org/* The Robert Wood Johnson Foundation: www.rwjf.org/* The Hogg Foundation: hogg1.lac.utexas.edu/