Inequities in Depression Management in Low‐Income, Minority, and Old‐Old Adults: A Matter of Access to Preferred Treatments?

According to Crystal et al.'s paper1 in this issue of the Journal of the American Geriatrics Society, the overall rates of diagnosis and treatment of depression in older adults has increased dramatically in recent years. Although the rates of depression diagnoses in elderly Medicare recipients reported by Crystal et al. are still lower than would be expected from epidemiological data,2 diagnoses have increased by more than 100%. Prescriptions for antidepressants have also increased dramatically, supporting recent survey data indicating that health providers are becoming more comfortable and knowledgeable in managing depression in their older patients.3, 4 Although this is positive news for older adults in general, Crystal et al.'s study also shows that positive trends in depression management seem to favor certain segments of the geriatric population—those who can afford supplemental insurance. Thus, older minorities and the old-old are less likely to access depression treatment. Furthermore, as the authors highlight in their discussion, there is little information regarding the quality of care delivered to older depressed adults. Even though health providers are more inclined to diagnose and treat depression in their older patients,3, 4 patients still may not be receiving effective depression care. Although Crystal et al.'s results regarding the inequities in diagnosis and service use by older minorities is unsettling, they are not unexpected. Regardless of age and even insurance status, minority populations tend to underuse mental health services.5 In a recent study of depressed older primary care patients,6 older men, Latinos, and African Americans were at particularly high risk for not receiving depression treatment. Several factors have been postulated as the cause of this inequity. Patient-level barriers have been identified with regard to the acceptability of mental health services by older minorities. Although the research on treatment preference in minority groups tends to be mixed, most of the literature indicates that older minorities who are distressed are amenable to mental health treatment7 and benefit from such treatment. Interestingly, Crystal et al.'s study echoes some of this research with utilization data. According to treatment-preference research, Latinos are more inclined to prefer medication treatment to counseling-based services, which could explain why Latinos were less likely to receive treatment overall and, if treated, less likely to receive psychotherapy.8 Medicare does not cover medication costs, which may partially explain the fact that Crystal et al. found less service use by older Latinos than other ethnic groups. An encouraging finding in Crystal et al.'s data that differs from recent studies in primary care6 was that older African Americans were as likely to receive treatment for depression as whites, although they were more likely to be treated with psychotherapy than with medication. These data also are consistent with survey data in African Americans who tend to report a preference for counseling-based interventions over medication.8, 9 Although the trend for African Americans in terms of service use is more optimistic than found for Latinos, the 50% copayment rates for psychotherapy under Medicare for poor African Americans is still a large barrier. According to one study,6 the rate of counseling use by African Americans is half that of whites and Latinos (4% vs 9%). Another important disparity found in Crystal et al.'s data is undertreatment of depression in the old-old age group (≥75). Far less research has been dedicated to understanding this particular inequity. Because patients with poorer self-reported health status had a higher probability of receiving treatment than those who had better perceived health status, it seems unlikely that undertreatment is associated with medical complexity, as would be expected in the old-old populations. The data suggest that advanced age is associated with lower treatment rates, but it is not clear whether older patients have other barriers to care such as less access to supplemental insurance. Other reasons could account for undertreatment in this sector of older adults. First, the old-old may be more likely to harbor stigma concerns about mental illness than younger geriatric cohorts. As cohorts age, we may see a shift in the degree to which stigma affects service use in the old old. Although age did not seem to affect diagnosis rates in Crystal et al.'s study, there could be a tendency by healthcare providers to minimize depression as an important issue in the old old. Despite providers' increased abilities to detect depression in older adults, studies are still showing that providers do not see the management of depression to be as important as they do in younger patients.10 Too many providers, patients, and family members may collude in the “Fallacy of Good Reasons,”11 which suggests that, because an older adult has multiple reasons to be depressed (such as advanced medical illness, multiple losses, or financial difficulties), treatment would not help. Although ethnicity and age are clearly important indicators of whether an older adult receives depression care, it appears that one of the main factors associated with disparities in rates of care is lack of health insurance coverage for services not currently covered under Medicare. Although not detailed in Crystal et al.'s paper, it may be that access to supplemental insurance that covers effective treatments such as antidepressant medications or psychotherapy has the potential for improving quality of care for all older adults. Finally, recent studies suggest that, although rates of diagnosis and antidepressant use have increased dramatically in recent years, many depressed older adults still do not receive effective treatment in usual care. A number of recent studies, such as the Improving Mood-Promoting Access to Collaborative Treatment Trial,12 have identified effective methods for improving the quality and effectiveness of depression care for older adults, but substantial barriers to the implementation of such models lie in the area of reimbursement. Such effective models of care for late-life depression rely on treatment with antidepressant medications, brief structured psychotherapy, and care management services provided by depression care managers that are not fully covered under current fee-for-service Medicare rules. Removing financial access barriers to such effective treatments may substantially improve rates and outcomes of care for all depressed older adults in diverse settings of care. In summary, Crystal et al.'s paper highlights important directions for the future of depression treatment in older adults. In particular, more attention must be paid to the inequities in the diagnosis and treatment of older minorities and the old old. Financial, attitudinal, and system barriers for these populations need to be better understood so that access to depression care can be increased. Finally, methods for reimbursing quality care that include a variety of treatment options and proper follow-up need to be developed and highlighted.