DISPARITIES IN THE DIAGNOSIS AND TREATMENT OF DEPRESSION

1
DISPARITIES IN THE DIAGNOSIS AND TREATMENT OF
DEPRESSION
2
Learning Objectives

• By the end of this presentation, participants
  will be able to
• Identify sources and trends of disparities in
  mental health care
• Discuss important issues in mental health care
  faced by members of cultural, ethnic, and racial
  populations
• Recognize gaps in, and barriers to, appropriate
  patient care for these populations
• Discuss current efforts that are directed at
  overcoming these barriers

3
Introduction

• Discrepancies in mental health care quality do
  exist
• General population may not receive the highest
  quality of care
• Racial and ethnic minorities experience greater
  gaps of care
• More incidents of unequal treatment in mental
  health care services than in other areas of
  medicine
• US Surgeon Generals Report states that racial
  and ethnic minorities are
• More likely to have lower socioeconomic status,
  which has been linked to increased incidence of
  mental illness
• Likely to be underserved and experience poorer
  quality of mental health

US Dept of Health and Human Services. Mental
Health Culture, Race, and EthnicityA Supplement
to Mental
Health A Report of the Surgeon General.
Rockville, MD 2001.
4
Sources of Disparities in Mental Health Care
US Dept of Health and Human Services. Mental
Health A Report of the Surgeon General.
Rockville, MD 1999.
5
Sources of Disparities in Mental Health Care
(cont)

• Overall, these populations experience
• Less access to, and availability of, mental
  health services
• Lower likelihood of receiving mental health care
• Lower quality of mental health care when received
• Greater burden of disability
• These populations may experience a heightened
  risk of mental disorders (eg, depression,
  anxiety) as a result of racism and discrimination

US Dept of Health and Human Services. Mental
Health Culture, Race, and EthnicityA Supplement
to Mental Health A Report of the Surgeon
General. Rockville, MD 2001.
6
Trends in Disparities 2005 National Healthcare
Disparities ReportQuality and Access
U.S. Dept of Health and Human Services. The
National Healthcare Disparities Report.
Rockville, MD 2005.
7
Sources of Disparities in MentalHealth Care

• Several distinctive factors define the
  disparities in the quality of care provided
• Socioeconomic factors1,2
• Access to care1,2
• Cultural issues1,2
• Prejudices among patients and health care
  providers2
• Low health literacy skills3

• Chow JCC. Am J Public Health. 200393792.
• US Dept. of Health and Human Services. Mental
  Health Culture, Race, and EthnicityA Supplement
  to Mental Health A Report of the Surgeon
  General. Rockville, MD 2001.
• Burroughs VJ. National Pharmaceutical Council,
  2002. http//www.npcnow.org/resources/PDFs/Cultura
  lFINAL.pdf.

8
Socioeconomic Status

• "An individual's or group's position within a
  hierarchical social structure. Socioeconomic
  status depends on a combination of variables,
  including occupation, education, income, wealth,
  and place of residence.1

• The American Heritage New Dictionary of Cultural
  Literacy, Third Edition. 2005. http//dictionary.r
  eference.com/browse/socioeconomic status

9
Socioeconomic Status (cont)

• Displays a strong link with health status1
• Impacts residential patterns2
• People with mental illnesses tend to be
  concentrated in high-poverty neighborhoods
• Lower socioeconomic status is linked with3
• Impoverishment and poor living conditions
• Chronic illnesses
• Unemployment
• Depression

• Pincus T et al. Ann Intern Med. 1998129406.
• Chow JC et al. Am J Public Health. 200393792.
• US Dept. of Health and Human Services. Mental
  Health Culture, Race, and Ethnicity A
  Supplement to Mental Health A Report of the
  Surgeon General. Rockville, MD 2001.

10
Socioeconomic Status (cont)

• Ethnic and racial minority populations tend to
  have lower socioeconomic status, and lower levels
  of1,2
• Education
• Income and job status
• Socioeconomic resources
• Social standing in the community

• US Dept. of Health and Human Services. Mental
  Health Culture, Race, and Ethnicity A
  Supplement to Mental Health A Report of the
  Surgeon General. Rockville, MD 2001.
• Bolen JC. Morb Mortal Wkly Rep Surveill Summ.
  2000491

11
Access to Care
Low Socioeconomic Status

• Low income1,2
• Limited/nonexistent insurance2
• Impoverished neighborhoods1
• Remote rural areas1
• Publicly run mental health centers
• Lack of resources1
• Few culturally/linguistically
• appropriate services1

Lack of access to care

• US Dept. of Health and Human Services. Mental
  Health Culture, Race, and Ethnicity
  A Supplement to Mental Health A Report
  of the Surgeon General. Rockville, MD 2001.
• Schraufnagel TJ. Gen Hosp Psychiatry.
  200628(1)27.

12
Access to Care (cont)

• Additional factors influencing access to care
  include
• Transportation issues
• Lack of availability or dependency on others for
  transport
• Unfamiliarity with public transit systems
• Child care
• Lack of transportation to childcare services
• Lack of affordable services
• Primary guardianship with no social support,
  which makes access to health care difficult
• Work schedules
• Loss of pay for time taken off for health care
  appointments

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14
Patient Barriers to Mental Health Care

• Patients may not accept a diagnosis of depression
  because of1
• Negative beliefs and attitudes about
  psychological illnesses
• Sociocultural norms
• Past health care experiences
• The wait and see dilemma2
• Patients may take this approach, delaying
  treatment and waiting for symptoms to resolve on
  their own
• Can be seen with depressive disorders with less
  severe symptoms

• Van Voorhees BW et al. Ann Fam Med. 2005338.
• Klinkman MS. J Clin Psychiatry. 200364(suppl
  2)19.

15
Patient Barriers to Mental Health Care (cont)

• Antidepressant treatment adherence1
• Varies broadly
• Premature discontinuation increases relapse risk
• Variables influencing adherence include
• Belief about the necessity of treatment
• Concerns about harms of treatment
• Poor health literacy2
• Can limit communication and cause difficulty with
  prescription instructions and medical testing
  information
• A study of 3260 new Medicare enrollees showed
  inadequate or marginal health literacy in
• 33.9 of English-speaking respondents
• 53.9 of Spanish-speaking respondents

• Aikens J et al. Ann Fam Med. 2005323.
• Gazmararian JA. JAMA. 1999281545.

16
Race, Culture, and Mental Health Care (cont)

• Culture is a shared set of beliefs, norms, or
  values that will influence the meaning given to
  life events and experiences1
• Health and health-seeking behaviors exist along a
  continuum of cultural and ethnic influences2
• Because care for all patients is culture-based,
  cultural competence is an essential aspect of
  health care
• Please see Transcultural Issues in the Diagnosis
  and Treatment of Depression for more information

• Schraufnagel TJ et al. Gen Hosp Psychiatry.
  20062827.
• Bolen JC et al. Morb Mortal Wkly Rep Surveill
  Summ. 2000491

17
Race, Culture, and Mental Health Care (cont)

• Ethnic minorities and immigrants face issues such
  as
• Poor communication because of lack of English
  fluency1,2
• Lack of familiarity with US health care system1
• Cultural attitudes about traditional and Western
  medicines3
• risk of psychological stress and mental
  illness because of environmental factors such
  as1
• History of political or religious persecution
• Acculturation stress
• Social isolation and rejection
• Racism and prejudice

• Jablensky A et al. J Refugee Studies. 19925172.
• US Dept. of Health and Human Services. Mental
  Health Culture, Race, and EthnicityA Supplement
  to Mental Health A Report of the Surgeon
  General. Rockville, MD 2001.
• Burroughs VJ. National Pharmaceutical Council,
  2002. http//www.npcnow.org/resources/PDFs/Cultura
  lFINAL.pdf.

18
Race, Culture, and Mental Health Care (cont)

• Depression screening instruments
• May not reflect the language and culture of
  African Americans, Hispanics, Asians, and other
  racial and ethnic groups
• Verbal descriptions of emotional concepts
  associated with depression tend to be unique to
  particular cultures

Rait G. Age Aging. 199827271
19
Race, Culture, and Mental Health Care (cont)

• Physician-patient interactions may vary because
  of
• Language barriers1 Different languages,
  expressions, mannerisms, levels of comprehension
• Differing customs and cultural/religious views2
• In some cultures, treatment decisions may be
  decided by the family, not the patient3
• Physicians may encounter patients who are
  reluctant to discuss a death in the family
  because of fear of invoking that spirits anger4
• Stigma surrounding mental illness can manifest as
  reluctance to discuss problems and seek treatment2

• Juckett G. Am Fam Physician. 200572(11)2267.
• Murray J et al. Soc Sci Med. 2006631363.
• Burroughs VJ. National Pharmaceutical Council,
  2002. http//www.npcnow.org/resources/PDFs/Cultura
  lFINAL.pdf.
• Hughes CC. Cultures Role in Clinical Psychiatric
  Assessment. In Okpaku SO (ed). Clinical Methods
  in Transcultural Psychiatry. Washington, DC
  American Psychiatric Press, Inc. 1998.

20
Race, Culture, and Mental Health Care (cont)

• Disease may present as culture-bound syndromes
• Variable presenting symptoms, influenced by
  culture
• Described in the DSM-IV-TR Glossary of
  Culture-Bound Syndromes
• Examples
• Shin-byung (Korean) Anxiety, somatic symptoms,
  including weakness and dizziness, dissociation,
  and possession by ancestral spirits
• Nervios (Latino) Latina women in particular
  experience this form of distress, which includes
  brain aches, irritability, sleep disturbances,
  trembling, and tearfulness
• Bouffee delirante (West African, Haitian) A
  sudden outburst of violent or agitated behavior,
  with marked confusion, excitement, and possible
  paranoid hallucinations

APA. DSM-IV-TR. Washington, DC APA 2000879.
21
Race, Culture, and Mental Health Care (cont)

• The DSM-IV-TRs Outline for Cultural Formulation
  helps the physician address each patients ethnic
  and cultural context of disease, including
• Cultural identity of the individual
• Cultural explanations of the individuals illness
• Cultural factors related to psychosocial
  environment and levels of functioning
• Cultural elements of the relationship between the
  individual and the clinician
• Overall cultural assessment for diagnosis and
  care

APA. DSM-IV-TR. Washington, DC APA 2000879.
22
Race, Culture, and Mental Health Care (cont)

• Ethnopsychopharmacology1
• Factors affecting individuals responses to
  medications can be
• People from different ethnic and racial
  backgrounds metabolize medications differently
• Black patients may require lower doses of
  tricyclic antidepressants (TCAs) and
  selective serotonin reuptake inhibitors (SSRIs)2
• Physicians should consider these factors and
  carefully monitor patients on medications
• Please see Transcultural Issues in the Diagnosis
  and Treatment of Depression, for more
  information on ethnopsychopharmacology

• Smith, MW. Ethnopsychopharmacology. In Lim RF
  (ed). Clinical Manual of Cultural Psychiatry.
  Arlington, VA AP Publishing, Inc. 2006207.
• Varner RV. Psychiatr Q. 199869117.

23
Race, Culture, and Mental Health Care (cont)

• Patients who are matched to a physician with a
  similar ethnic background tend to be more
  satisfied1
• Survey by Crystal et al, 20032
• Patients belonging to certain subgroups were less
  likely to receive any treatment if diagnosed with
  depression, including those of Hispanic or
  other ethnicity
• Those patients who received treatment were less
  likely to receive psychotherapy in addition to,
  or in place of, pharmacotherapy

• Cooper-Patrick L. JAMA. 1999282(6)583.
• Crystal S. J Am Geriatr Soc. 200351(12)1718.

24
Race, Culture, and Mental Health Care (cont)

• Psychotherapy Minority individuals may not
  participate because of stigma surrounding its use
  
• Can be seen in some African American, Asian
  American, and Hispanic cultures
• Discouragements to using mental health services
  may also include
• Lack of counselors trained in culturally
  sensitive therapy models
• Lack of bilingual counselors
• Lack of counselors with similar ethnic/racial
  backgrounds
• Lack of cultural sensitivity

Kearney LK. The Counseling Mental Health Center
2003 Research Consortium. http//www.utexas.edu/st
udent/cmhc/research/rescon.html
25
Race, Culture, and Mental Health Care (cont)

• Whites have been shown to attend mental health
  therapy sessions significantly more often than
  African American, Asian American, and Hispanic
  individuals1
• However, another study demonstrated that, among
  the Asian population, East Asians used these
  services more than whites, African Americans,
  Latinos, Native Americans, and other Asian
  populations2
• More research is needed regarding mental health
  therapy use and outcomes among racial and ethnic
  minorities1

• Kearney LK. The Counseling Mental Health Center
  2003 Research Consortium. http//www.utexas.edu/st
  udent/cmhc/research/rescon.html
• Barreto RM. Psychiatric Services. 200556746.

26
Barriers to Appropriate CarePatient Factors

• Mistrust
• Noted in many racial and ethnic groups because of
  personal or cultural experience with foreign
  governments or cultures (ie, Native Americans,
  refugees)1-3
• Studies of non-Hispanic blacks and non-Hispanic
  whites found that African Americans are1,2
• Less likely to trust their physicians and/or
  hospitals
• More likely to report concerns of privacy and
  harmful experimentation
• Likely to perceive racism
• Likely to report less satisfaction with overall
  care

• Boulware LE et al. Public Health Rep.
  2003118358.
• LaVeist TA et al. Med Care Res Rev. 200057146.
• US Dept. of Health and Human Services. The
  National Healthcare Disparities Report.
  Rockville, MD 2005.

27
Barriers to Appropriate CareEconomic Factors

• 16.318.3 of non-elderly adults are uninsured1
• 50 of these are racial and ethnic minorities
• Ethnic minorities are more likely to be uninsured
  than whites1,2
• Lower rates of job-based insurance for minorities
• Gaps between private and public health insurance
  for underserved and racial/ethnic minorities
• Many working poor are ineligible for Medicaid
• Increasing out-of-pocket expenses
• Cutbacks in employer-based benefits and higher
  co-payments may widen the coverage gap for many
  minority patients

• Kaiser Commission on Medicaid and the Uninsured.
  Who are the Uninsured? A Consistent
  Profile Across National Surveys. 2006.
• UCLA Center for Health Policy Research, Kaiser
  Family Foundation. Policy Research Report 1525.
  2000.

28
Barriers to Appropriate CarePhysician Factors

• Physician prejudice
• Physicians are less likely to detect mental
  health problems in racial/ethnic minority
  patients1
• Physicians may unjustly characterize mental
  health issues as religious or culturally-sanctione
  d belief systems2
• Physicians tend to offer different types and
  qualities of treatment across ethnic/racial
  minority groups3
• One study showed that African-American patients
  were prescribed depression medication at a lower
  rate than white patients, and tended to receive
  older, less tolerable antidepressants3

• Borowsky SJ et al. J Gen Intern Med. 200015381.
• Chow JC et al. Am J Public Health. 200393792.
• Melfi CA et al. J Clin Psychiatry. 20006116.

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30
Overcoming Barriers

• Cultural Competence
• a group of skills, attitudes, and knowledge
  that allows persons, organizations, and systems
  to work effectively with diverse racial, ethnic,
  and social groups.1

• US Department of Health and Human
  Services.Healthy People 2010 Progress
  ReviewFocus Area 18 Mental Health Mental
  Disorders. 2004. http//oas.samhsa.gov/MentalHealt
  hHP2010/terminology.htm

31
Overcoming BarriersOrganizational Cultural
Competence

• Initiatives for provider and organization
  education and outcomes research may
• Improve physician and organizational competence1
• Decrease standing barriers to care for
  minorities,1 such as
• Poor communication due to language barriers2
• Poor access to culturally competent care2
• Perceived racial/ethnic biases from providers and
  organizational staff in public and private health
  care sectors3
• Physician bias in diagnosis and treatment of
  depression in minority patients4

• Beach MC. BMC Public Health. 20066104.
• Juckett G. Am Fam Physician. 200572(11)2267.
• LaVeist TA. Med Care Res Rev. 200057(suppl
  1)146.
• Whaley AL. Am J Orthopsychiatry. 199868(1)47.

32
Overcoming BarriersManaged Mental Health Care
for Minorities

• Possible benefits include
• Flexibility of care options to patients
• Cost-efficient, accurate, and effective
  assessment and treatment
• Culturally competent, community-based treatment
• Use of traditional healers in conjunction with
  traditional western mental health approaches
• Increased access to office/specialist visits vs
  emergency department visits
• Effective physician/staff education on depressive
  disorders in racial/ethnic groups
• Greater overall access to treatment at regional
  level (eg, regional PPOs under Medicare MC plans)

US Department of Health and Human Services. 2001.
http//mentalhealth.samhsa.gov/publications/allpu
bs/SMA00-3457/intro.asp
33
Overcoming BarriersPhysician Cultural Competence

• Cultural awareness and communication lessons
• A recent study evaluated hands-on clinical
  encounters with refugee patients and found that
  medical students had developed
• Increased awareness of interpretation services
  and cross-cultural communication
• Increased awareness of patients cultural
  backgrounds
• Deepened reflection on their own culture and
  cultural humility
• Validation of the rationale for empathetic care
  and patient empowerment

Griswold K et al. J Immigr Minor Health. 2006.
(Epub ahead of print)
34
Overcoming BarriersPhysician Cultural Competence
(cont)

• Physician training curricula focusing on cultural
  humility and self-assessment of biases can
  increase
• Cultural awareness
• Effective communication
• Sensitivity to each patients perspective and
  social context
• Patient involvement during the office visit

Juarez JA et al. Fam Med. 20063897.
35
Overcoming BarriersPhysician Cultural Competence
(cont)

• Increased physician awareness of
  ethnopsycho-pharmacology can help
• Provide patients with appropriate treatment
  choices, including optimal therapeutic agents and
  doses
• Ensure adequate response to treatment
• Prevent side effects and toxicities
• For more information on ethnopsycho-pharmacology
  and efforts to improve physician competence,
  please see the accompanying module, Transcultural
  Issues in the Diagnosis and Treatment of
  Depression

Smith MW. Ethnopsychopharmacology. In Lim, RF
(ed). Clinical Manual of Cultural Psychiatry.
Arlington, VA American Psychiatric Publishing.
2006207.
36
Overcoming BarriersCLAS Standards

• Culturally and Linguistically Appropriate
  Services (CLAS)
• Released in 2000 from the Office of Minority
  Health (OMH)
• Recommended national standards for adoption
  and/or adaptation by health care organizations in
  order to offer culturally and linguistically
  accessible health care
• Consist of 14 standards

US Dept. of Health and Human Services, 2001.
http//www.omhrc.gov/assets/pdf/checked/finalrepor
t.pdf
37
Overcoming BarriersCLAS Standards

• Standards 13, 813
• Guidelines recommended by OMH for adoption as
  mandates by federal, state, and national
  accrediting agencies
• Focus Culturally compatible care, diverse
  staffing, formulation of a strategic plan,
  institution of competence-related measures,
  community involvement, and needs assessment
• Standards 47
• Federal mandates for recipients of federal
  funding
• Focus Language access and language resource
  availability
• Standard 14
• Recommendation suggested for voluntary adoption
  by health care organizations
• Focus Public availability of information about
  progress and implementation of CLAS standards

US Dept. of Health and Human Services, 2000.
http//www.omhrc.gov/assets/pdf/checked/finalrepor
t.pdf
38
State and Federal Requirements for Cultural
Competency Are Increasing

• California As of July 1, 2006,1 licensed
  physicians must include cultural competency and
  linguistics in CME (Assembly Bill 1195)1-3
• New Jersey Physicians must complete cultural
  competency training to obtain a medical license
  from the State Board of Medical Examiners
  (Assembly Bill S144)2
• Washington state By July 1, 2008, educational
  programs for health professionals must integrate
  multicultural health instruction into their basic
  education preparation curriculum4
• Other bills have been passed, or are under
  consideration, in various states, including2

• University of California, Davis CME Summary and
  Initiatives for Compliance. http//www.ucdmc.ucdav
  is.edu/cme/resources/ucd_summary.pdf
• Underserved Quality Improvement Organization
  Support Center. CLAS Implementation Guide.
  http//www.qsource.org/uqiosc/CLASGuide.pdf
• Assembly Bill No. 1195. http//www.healthlaw.org/l
  ibrary.cfm?fadownloadresourceID78947appViewfo
  lderprint
• Engrossed Senate Bill 6194. http//www.leg.wa.gov/
  pub/billinfo/2005-06/Pdf/Bills/Session20Law20200
  6/6194.SL.pdf

39
Overcoming BarriersFederal Requirements

• Currently, more than 14 states have Medicaid and
  Medicare contracts with cultural competency
  requirements, as required by the federal
  government1
• JCAHO, the national accrediting body for
  hospitals, is working with the government to
  develop cultural competency mandates
• Helped develop the national Culturally and
  Linguistically Appropriate Services standards
  (CLAS)1
• As of 2006, CLAS standards have been
  crosswalked with JCAHO standards for hospitals,
  ambulatory, behavioral health, long term care,
  and home care2

• U.C. Davis Health System. Cross cultural
  competency program. http//www.ucdmc.ucdavis.edu/h
  r/hrdepts/eod/cross_cultural_competency.html.
• Joint Commission on Accreditation of Healthcare
  Organizations. 2006. http//www.jointcommission.or
  g/NR/rdonlyres/5EABBEC8-F5E2-4810-A16F-E2F148AB517
  0/0/hlc_omh_xwalk.pdf

40
Institute of Medicine 2005 ReportImproving the
Quality of Healthcare for Mental and
Substance-Use Conditions

• IOMs comprehensive strategy to reduce gaps in
  care includes
• A system in which patient preferences, needs, and
  values prevail
• Coordinated care of the patient by multiple
  providers
• An infrastructure that produces scientific
  evidence and promotes its application to patient
  care

Institute of Medicine. Improving the Quality of
Health Care for Mental and Substance-Use
Conditions Quality Chasm Series. 2005.
41
Institute of Medicine 2005 ReportImproving the
Quality of Healthcare for Mental and
Substance-Use Conditions (cont)

• IOMs comprehensive strategy to reduce gaps in
  care also includes
• Delivery of high-quality health care, supported
  by
• Health care workforce education, training, and
  capacity to deliver
• Government programs, employers, and other group
  purchasers
• Research funds supporting studies with direct
  clinical/policy impact and/or therapeutic
  advances
• Emerging information technology related to health
  care benefits

Institute of Medicine. Improving the Quality of
Health Care for Mental and Substance-Use
Conditions Quality Chasm Series. 2005.
42
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43
Decreasing DisparitiesRecognizing Gaps in Care

• New approaches are needed to identify
• Sources of disparities
• Corrective measures for disparities
• Disparities in estimates of the prevalence of
  psychiatric disorders in different racial/ethnic
  groups can be analyzed from models of
• Sociocultural influences
• Self-selection
• Social selection
• Clinician bias

44
Decreasing DisparitiesQuality Improvement Efforts

• Focusing on depression care in individuals of
  lower socioeconomic standing will
• Enhance overall mental health of the population
• Reduce the burden of illness on society
• Investigating quality improvement strategies that
  bridge specialty and primary care may improve
  rates of appropriate care for minority
  populations1

• Miranda J et al. Health Serv Res. 200338613.

45
Decreasing Disparities in Depression
CareImproving Treatment

• The approach to depression treatment is
  heterogeneous, with widely varying adherence to
  treatment guidelines1-3
• Need to further examine treatment aspects such
  as
• Diagnostic criteria
• Treatment consistency
• Barriers to guideline adherence
• Physician education and impact on practice
  patterns

• Burman ME. J Am Acad Nurse Pract. 200517370.
• Charbonneau A. Am J Manag Care. 200410846.
• Robinson WD. J Am Board Fam Pract. 20051879.

46
Decreasing Disparities in Depression
CareImproving Treatment (cont)

• More accessible guidelines specific to long-term
  management of depressive disorders in primary
  care are needed1
• Consistent nomenclature problems exist with
  diagnostic classification that can impact
  outcomes and appropriate identification of the
  individual disorder2-5
• Psychotherapy6
• Lack of supportive psychotherapy in many patients
• Combination of supportive psychotherapy plus
  appropriate pharmacotherapy may improve outcomes

• Klinkman MS. J Clin Psychiatry. 20036419.
• Jager M. Psychopathology. 200437110.
• Erkinjuntti T. N Engl J Med. 19973371667.
• McCabe RJ. Euro Child Adol Psych. 19965147.
• Okasha A. Br J Psychiatry. 1993162621.
• Crystal S. J Am Geriatr Soc 2003
  December51(12)1718.

47
Decreasing Disparities in Depression
CareConclusions

• Adequate management of depression must account
  for each patients
• Socioeconomic issues, including
• Cultural and ethnic backgrounds and traditions
• Access to care and follow-up visits
• Medication costs
• Social support system availability
• Ethnopsychopharmacology
• Treatment preferences
• African Americans, Hispanics, and Asian Indians
  with mental illness are more likely to prefer
  psychotherapy, and less likely than whites to use
  prescription drugs1,2

• Cooper LA. Health Serv Res. 200338613.
• Harman JS. Psychiatr Serv. 2004551379.

48
Decreasing Disparities in Depression
CareConclusions (cont)

• There are unmet needs in recognizing and
  diagnosing depression, especially in populations
  underserved by the current health care system
• Disparities in diagnosis and treatment must be
  recognized in order to promote quality care
• For more information on cross-cultural issues in
  depression care, please refer to the accompanying
  modules
• Current Practices in the Diagnosis and Treatment
  of Depression Best Practices in Primary Care
• Transcultural Issues in the Diagnosis and
  Treatment of Depression

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