As the population increases and people live longer than previous generations, a significant number of older people will need treatment for mental disorders. Depression is one of the most prevalent mental disorders among older adults, including ethnic and racial minorities, and is a leading cause of disease burden and disability in the US and abroad. Part of this burden is attributable to the fact that depression is often comorbid with medical conditions, it impairs cognition, and it leads to significant disability with an increased risk of suicide and all-cause mortality.
Late-life depression is defined in this article as unipolar depressive syndromes that older adults experience, typically around age 60 or older: major depression, dysthymic disorder, adjustment disorder with depressive features, and clinically significant depressive symptoms or minor depression. The prevalence of depression is 15% to 20% each year for older adults; for major depression, prevalence is 1% to 4% in the general population and up to 14% in nursing home residents.1,2 The prevalence of minor depression is 4% to 13%, while dysthymic disorder occurs in about 2% of the older adult population.3 For people living in long-term–care settings, the rates of minor depression or clinically significant symptoms of depression range from 17% to 35%.
Although depressive disorders are less frequent in older adults than in those who are younger, older adults report higher levels of depressive symptoms than their younger counterparts, and symptom remission is less likely in the elderly.4 As with younger adults, the course of depression in older populations is marked by exacerbations, remissions, and chronicity—60% of older adults who recover from a major depressive episode have a subsequent episode, and up to 40% of depressed older adults can experience relapse and chronicity.5 Thus, even subthreshold or subclinical levels of depression that do not necessarily meet DSM-IV diagnostic thresholds can be disabling.
Greater disability is associated with higher prevalence of depression and risk among the elderly. Those with complete impairment in a least 2 domains of living are at highest risk for major depression (up to 31.5%).6 The mechanisms implicated in the relationship between disability and depression include both individual (eg, heightened sensitivity to acute and chronic stress, biological pathways such as increased proinflammatory and cortisone activity) and external factors (eg, environmental stress exposure).
Depression-related disparities among older, low-acculturated US Latinos
Latinos represent the fastest-growing segment of the older adult population. With an increase from 6% in 2006 to 18% in 2050, they will account for the largest racial/ethnic minority group over age 65 by 2028.7 Among adults aged 50 and older in need of depression treatment, less than half access services. Considerable evidence exists that older US racial and ethnic minorities experience significant mental health disparities in depression burden and access to quality mental health treatment. Older minorities with depression report higher levels of impairment and are more persistently ill than non-Hispanic white older adults, yet they have lower utilization of mental health care.
A comprehensive review by Fuentes and Aranda8 found that of 1068 articles, only a handful of depression treatment studies actually reported racial- or ethnic-specific outcomes pertaining to older minorities. Although there has been an increase in the proportion of Americans who are treated with antidepressants, older minorities report higher rates of depression-related disability and longer duration of the depression, and they are less likely to receive any type of therapy or guideline-concordant depression care.9
Older Latinos have up to double the rates of clinically significant depression compared with both whites and blacks in similar population-based studies.10 Prevalence for major depression is higher (about 28%) among minority patients in urban settings.11 Although immigrant young Latinos have better mental health outcomes than US-born Latinos for select disorders, older immigrant and low-acculturated (ie, limited English-speaking and retaining country of origin beliefs, traditions, communication patterns, and help-seeking behaviors) Latinos tend to be at higher risk for depression.10,12 Yet, the situation is compounded by the fact that older Latino immigrants report low service utilization despite elevated rates of dysthymia and anxiety disorders.13 Correlation data indicate that elevated depression rates in older Latinos are associated with female sex, older age, low income, low social support, high stress, chronic financial strain, functional decline, and low acculturation.14
What new information does this article provide?
Older Latinos with depression report higher levels of impairment and are more persistently ill than non-Hispanic white older adults, yet they have lower rates of guideline-concordant treatment. Cognitive and problem-solving psychosocial modalities are emerging as key treatment considerations for older Latinos.
What are the implications for psychiatric practice?
Personalized and culturally congruent psychosocial care should include assessment of cultural preferences for the following: (1) language of treatment encounters, (2) discussions regarding medication effects, (3) inclusion of family and social networks in treatment goals, (4) case management and brokering of community-based services, and (5) collaboration with primary care physicians regarding treatment for comorbid medical conditions.
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