Blacks with depression and diabetes receive inadequate mental health treatment

A new study in General Hospital Psychiatry confirms that Blacks with depression plus another chronic medical condition, such as Type 2 diabetes or high blood pressure, do not receive adequate mental health treatment.

Those who do seek treatment for depression often receive medications from a primary care provider, the authors said, and are less likely to have care from specialized mental health providers. Consequently, those patients are less likely to receive mental health treatment recommended by American Psychiatric Association (APA) guidelines. Primary care is rarely adequately resourced to provide long-term mental health treatment.

"People who have depression are more likely to develop type 2 diabetes and vice versa," said lead study author Amma A. Agyemang, M.S., M.P.H. of Virginia Commonwealth University's psychology department. "We found depression treatment below par for minorities, even those with co-morbid diabetes or hypertension. Having a mental illness and a medical illness makes both more complex to treat, and the rate of obtaining depression treatment remains low for this population."

The research team utilized cross-sectional data obtained between 2001 and 2003 from the National Survey of American Life. They were particularly interested in two opposing hypotheses: exposure or crowd-out effects. The former occurs when a person has both a mental and medical illness, said Agyemang. A provider helps manage the medical illness, and will be more likely to inquire about mental health. In contrast, crowd-out effects occur when a medical illness like type 2 diabetes demands more focus, resulting in inadequate mental health care.

Overall, they found that only 19.2 percent of Black Americans with major depression alone, 7.8 percent with depression plus type 2 diabetes and 22.3 percent with depression plus hypertension reported receiving psychotherapy or antidepressant treatment in accordance with APA guidelines. Compared to respondents with major depression alone, respondents with two health conditions, either major depression and type 2 diabetes or major depression and hypertension, were no more likely to receive depression care. Respondents with all three health concerns: depression, type 2 diabetes and hypertension were, however, three times more likely to report any guideline-concordant care

"Depression has lower rates of detection and treatment among Blacks compared to Whites—a well- known health disparity—and we know depression is more disabling and chronic among Blacks," said Shervin Assari, M.D., M.P.H., a research fellow at the Department of Psychiatry and Center for Research on Ethnicity, Culture, and Health at the University of Michigan School of Public Health. "The good news for treatment of depression among Blacks is a higher chance of treatment of depression in the presence of medical multi-morbidity. The bad news for depression treatment among Blacks is lower quality of depression treatment in this case. They do not receive the most effective, evidence- and guideline-based treatment."

Mental health conditions in general and depression in particular are associated with high stigma among Blacks, keeping them away from psychiatric services, Assari added. "African Americans may also have lower trust in the health care system. Black patients who have multiple medical conditions may have a higher likelihood of treatment, however, the treatment may not be based on standard guidelines. Diagnostic tools are designed based on White patients and are not sensitive to patients' cultures. Physicians also do not receive enough training for detection and diagnosis of mental health illnesses among minority groups."

Hopefully, that will change, observed Agyemang. "As the discipline of psychology continues moving closer to really integrating mental health services into broader medical settings, perhaps we can close the gap in mental health treatment and health disparities for minority populations."