Major depressive disorder (MDD) is often stigmatized, so it is not surprising that the disease goes undiagnosed and undertreated in certain populations.1 Ethnic and racial minorities, as well as young people, may be challenged by their own attitudes toward seeking care for MDD.1 MDD is a major health burden globally — with 5% to 7% of the population reporting such symptoms annually — clinicians and researchers are seeking ways to reduce the burden of illness and provide access to treatment.2

How Racism Affects Depression

While MDD is more pervasive in the white population, blacks are more likely to experience long-term, chronic, and debilitating depression.1 As research is underway to better understand the cumulative effect of social oppression in ethnic and racial groups, risk factors known to contribute to poor mental health include low income, socioeconomic positioning, and unemployment.1

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To help clinicians make more appropriate treatment choices, the Patient-Centered Culturally Sensitive Health Care is an assessment tool that enables them to see health disparities and how they can provide more individualized care.1 Patients whose clinicians have used the tool reported higher satisfaction with their treatment.1

Knowing that certain patients are less likely to seek help for depression may also alert clinicians to intervene sooner. Overall, 39% of black women and 30% of black men vs 51% of men who are not of African descent were likely to seek treatment.1

Why Some Men Suffer in Silence

A study of working-class men (N=12; mean age, 40.42 years) found that they have difficulty acknowledging depression and are consequently reluctant to seek treatment, due to the social stigma.3 The qualitative study conducted by psychologists James R. Mahalik, PhD, from Boston College, Chestnut Hill, Massachusetts, and Faedra R. Dagirmanjian, PhD, from Pace University, New York City, conducted in-depth interviews with men who worked in mostly male-dominated manual labor.3

As to why the men did not seek help for depression or sadness, the main themes focused on weakness and loss of masculinity for doing so.3 Some examples of what provided  relief for the men included speaking with women about their problems and experiencing trust during discussions.3

Vulnerability in College Students  

University students are another population that is undertreated for depression, largely due to the stigma surrounding mental health.4 Doctoral student Leslie Rith-Najarian from the University of California in Los Angeles, and colleagues, conducted 2 parallel studies on large university campuses on the West (N=651) and East Coast (N=718) to determine how great the unmet need was for depression treatment in college students.4

In an appeal to the students’ vanity and to reduce the stigma surrounding depression, the researchers branded the online mental health programs “The Happiness Challenge” or “ReBoot Camp.” Participants responded to email and bulletin board ads for either program, during which they took an online assessment for a baseline score of their depression.4

The aggregate unmet need for depression services was seen in more than one-third of the individuals who answered the ads, highlighting the need to reach out to students who would not otherwise seek treatment. A disproportionate number of women and Asian students answered the ads, with men more likely to choose the “ReBoot Camp” program vs the “Happiness Challenge.”4

Online Programs Alleviate Treatment Barriers

Indeed, online programs delivering cognitive behavioral therapy may be more palatable to individuals who hesitate to seek help for depression.2 Children and adolescents are natural fits for this treatment method because they are so accustomed to using devices.5

Psychiatrist David E. Roth, MD, from Honolulu, Hawaii, and colleagues offer tips for telepsychiatry for pediatric patients.5 When conducting online psychiatry services, he advises clinicians to:

  • Situate themselves in a private room with minimal distractions.
  • Dress professionally and maintain good posture throughout the video session to instill confidence in patients.
  • Use appropriate gestures (eg, fist bumps with children, nodding to encourage patients) and smile to project friendliness and promote trust.5

To reduce the stigma of depression, Dr Roth suggested, “The more it can be seen as a disruption in the functioning of the brain as an organ, the less it is seen as a personal weakness. No one would get mad at someone who has to cough, why blame them for symptoms of depression?”

Depression in Older Adults

While younger people tend to have more severe depression, older people are more likely to be depressed as they age.6 The challenge in diagnosing elderly people with depression is that their comorbidities may confound the diagnosis and polypharmacy may hinder treatment.6 In a review of 1603 unique articles, Rob M. Kok, MD, PhD, from the Parnassia Psychiatric Institute in The Hague, The Netherlands, and Charles F. Reynolds III, MD, from the University of Pittsburgh Medical Center in Pennsylvania, sought to uncover best practices for treating later-life depression.

“I sincerely hope that clinicians would approach older adults with depression the same as they approach younger adults with depression, because therapeutic nihilism (at older age, antidepressants are less effective and older people are reluctant to have psychotherapy) is a major contributor to under-treatment of older adults,” said Dr Kok. “Simply telling patients that a depression is a depression at any age, and the antidepressants or psychotherapy work at any age, is often enough for patients and their relatives.”

An 11-study qualitative systematic review of older adults’ attitudes toward depression confirmed these findings: for mild depression, the elderly consider self-help first, including socializing and praying.7 For major depression, however, elderly patients accept medical interventions, such as pharmacotherapy and psychosocial counseling noted lead investigator Pushpa Nair, MBBS, BSc, from University College London, United Kingdom.7

“Clinicians should discuss the risks and benefits of different approaches and the older person’s experience with these so they can make an informed choice,” Dr Nair advised. “[They] should also be aware of the impact of societal and structural factors, such as ethnicity, stigma and ageism. Ageism, for example, can lead to a reluctance on the part of some older adults to use up treatment resources from younger people.”

Summary and Clinical Applicability

The paradox of depression treatment is that patients who most need it are often the ones who have difficulty accessing care due to stigma, attitudes toward mental health, and lack of access. Healthcare professionals need to adapt their approaches with different populations to ensure access to care.

References

1. Bailey RK, Mokonogho J, Kumar A. Racial and ethnic differences in depression: current perspectives. Neuropsychiatr Dis Treat. 2019;15:603-609.

2. Batterham PJ, Calear AL, Sunderland M, Kay-Lambkin F, Farrer LM, Gulliver A. A brief intervention to increase uptake and adherence of an online program for depression and anxiety: protocol for the Enhancing Engagement with Psychosocial Interventions (EEPI) randomized controlled trial. Contemp Clin Trials. 2019;78:107-115.

3. Mahalik JR, Dagirmanjian FR. Working-class men’s constructions of help-seeking when feeling depressed or sad. Am J Mens Health. 2019;13(3):1557988319850052.

4. Rith-Najarian L, Sun W, Chen A, et al. What’s in a name? Branding of online mental health programming for university students. J Consult Clin Psychol. 2019;87(4):380-391.

5. Roth DE, Ramtekkar U, Zeković-Roth S. Telepsychiatry: a new treatment venue for pediatric depression. Child Adolesc Psychiatr Clin N Am. 2019;28(3):377-395.

6. Kok RM, Reynolds CF 3rd. Management of depression in older adults: a review. JAMA. 2017;317(20):2114-2122.

7. Nair P, Bhanu C, Frost R, Buszewicz M, Walters KR. A systematic review of older adults’ attitudes towards depression and its treatment [published online May 22, 2019]. Gerontologist. doi:10.1093/geront/gnz048