Getting treatment for depression may sometimes be a regular part of health care for the “worried well” that leaves those who cannot afford it to suffer by themselves.
A new study published Monday in JAMA Internal Medicine illustrates that phenomenon. Most Americans who screen positive for depression don’t receive treatment — while most who did receive treatment don’t actually have the condition.
“Over the last several years there has been an increase in prescription of antidepressants,” said Mark Olfson, professor of psychiatry at the Columbia University Medical Center and lead author of the study. “In that context, many people assumed that under-treatment 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 includes questionnaires screening 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 them received any treatment for it.
“The findings highlight that there are continuing challenges in aligning depression care with patient needs,” he said.
Adults in the lowest income group were five times more likely to be depressed compared with those in the highest income group. But they, along with uninsured adults, racial and ethnic minorities, and men, were also less likely to receive treatment.
On the other hand, among the 8.1 percent of adults who received treatment for depression, only 29.9 percent of them had depression and 21.8 percent of them had serious psychological distress. And those with either less serious or no depression were more likely to receive antidepressants. It’s a problem of overprescription, Olfson said, because studies have shown that antidepressants are not any more effective for patients with mild depression than a placebo.
“Being a little less aggressive in medication in mild depression would be beneficial,” he said. “There are simpler forms of psychological interventions that can be adapted for primary care.”
Rather than relying on these drugs, the patients can be given other treatments ranging from counseling and exercise to yoga.
In addition, researchers concluded that those with serious psychological distress are more likely to be treated by psychiatrists instead of general medical professionals, but this trend does not translate to older patients, African Americans, the uninsured or those with less education.
“Some when they have depression don’t believe they require treatment or that they could benefit from treatment,” Olfson said. “People are visiting doctors but the attention is to current, pressing medical problems.”
But these doctor visits can be used as an opportunity for increasing access to treatment for depression to disadvantaged populations. Olfson found that most people with untreated depression make at least one visit to a primary care doctor annually. If depression screening and mental health services can be integrated into primary care, Olfson said, there will be better access and awareness about the illness.
“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 said. “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 assistant professor at Harvard Medical School, agrees on, but he said 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.
“(For example) African Americans and Latinos prefer antidepressants less than whites,” Cook said. That might be an underlying reason “not to go for mental health treatment, why they might not stay at treatment for as long.”
This integration of services would also benefit patients who are over treated — those who receive antidepressants when they don’t need to. Olfson said many primary care doctors expressed frustrations in finding mental health professionals particularly in small and rural areas, so prescribing antidepressants might become their go-to when they don’t have resources. If there is a mental health professional right in the clinic, patients might get access to more services that a general doctor cannot offer such as counseling and psychotherapy.
“Depression really is a serious condition and we’re finding that so many Americans aren’t receiving care,” he said. “I hope that it (this study) brings attention to this situation.”
