Depression is the leading cause of disability and a major contributor to the global burden of disease as measured in disability-adjusted life years, according to a report in 2017 by the World Health Organization.1 By 2030, depression is projected to become the world’s largest contributor to disability-adjusted life years.2 Patients with depression are more likely to have chronic comorbid medical conditions such as diabetes and congestive heart failure and are more likely to be nonadherent to prescribed medications. Patients with untreated depression have higher medical costs, worse health outcomes, and lower quality of life than those whose depression is treated.
Disparities in treatment
There are tremendous disparities in the treatment of depression. Racial and ethnic minorities face both practical and cultural barriers to mental health care. They frequently lack the resources to seek help, suffer from language barriers, and hold strong convictions of stigma about psychiatric illnesses. These obstacles lead to under-recognition and undertreatment of mental illnesses. The Surgeon General’s Report considered correcting these disparities a top priority and suggested offering minority-centered services and developing culturally competent care to address the specific needs of minorities.3
Research has shown that the mental health care system provides less care to African Americans, who also are less likely to seek mental health care than white Americans. When African Americans seek mental health care, they are less likely to be satisfied with the care they receive—and more likely to leave treatment prematurely.4 This can be explained by a history of mistrust of medical professionals that originated from unethical treatment of racial and ethnic minorities in research and practice, which led a greater proportion of minorities to be skeptical of mental health care. These help-seeking behaviors may explain why African Americans with major depression are more likely to experience higher degrees of functional limitation.5
Asian Americans have their distinctive patterns of illness beliefs. When depressed, Asian Americans tend to focus on physical symptoms and under-report mood and anxiety symptoms. They usually prefer to seek help from primary care physicians (PCPs), lay people, and alternative medical practices, and rarely utilize mental health services.6 This help-seeking behavior makes primary care an important setting for identifying and treating depressed Asian Americans, yet depression is frequently under-recognized and undertreated in primary care.
The tendency of depressed Asian Americans to focus on their physical symptoms renders depression particularly difficult to identify in this population. When PCPs recognize depressed Asian Americans, they frequently feel that they lack the cultural understanding to effectively and sensitively communicate to patients about their illness. PCPs worry that informing their patients about MDD may provoke stigma against having mental illness. Under-treatment of depression among Asian Americans remains a significant public health problem in the US.
Collaborative management in primary care
The Chronic Care Model has been shown to improve outcomes in many chronic diseases, including diabetes, congestive heart failure, asthma, hyperlipidemia, and depression. Proposed by Wagner and colleagues,7 it includes the following strategies:
1. Population-based care
2. Use of treatment protocols with proven effectiveness for clinical management
3. Patient-centered collaborative goal setting
5. Planned and regular follow-up visits
6. Care management
Dr. Yeung is Associate Professor of Psychiatry, Harvard Medical School, Boston, MA. Dr. Yeung reports no conflicts of interest concerning the subject matter of this article.
1. World Health Organization. Depression Fact Sheet; February 2017. http://www.who.int/mediacentre/factsheets/fs369/en/. Accessed November 2, 2017.
2. World Health Organization. Depression, A Global Crisis; 2012. http://www.who.int/mental_health/management/depression/wfmh_paper_depression_wmhd_2012.pdf. Accessed November 2, 2017.
3. US Department of Health and Human Services. 1999. Mental Health: A Report of the Surgeon General–Executive Summary. https://profiles.nlm.nih.gov/ps/access/NNBBHS.pdf. Accessed November 2, 2017.
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