Psychiatr News October 20, 2006
Volume 41, Number 20, page 18
© 2006 American Psychiatric Association
Depression Definition May Underlie Racial Disparities
Mark Moran
Qualitative research in African-American communities suggests that many
black people who report depressive symptoms are likely to attribute those
symptoms to difficult life circumstances rather than to a treatable medical
condition.
The "clinical significance" criteria for major
depression—defined in important community epidemiologic surveys as a
history of receiving care for depression or significant interference with life
or usual activities—may cause rates of depression for African Americans
to be underestimated in those surveys.
That was the finding from an analysis of data from the 1999 National Health
Interview Survey for a nationally representative community sample of more than
30,000 adults administered the depression module of the composite
International Diagnostic Interview-Short Form.
In that analysis researchers found that there were no differences between
African-American and white or other individuals when depression was determined
solely on the basis of symptoms. But the same African Americans who reported
symptoms of depression were less likely than whites to report receiving care
and less likely to say the depression caused interference with their ability
to function.
The analysis was reported in the September American Journal of
Psychiatry.
Lead author James Coyne, Ph.D., told Psychiatric News that the
"clinical significance" criterion added in DSM-IV was a
change that had been intended to be a relatively innocuous new descriptor. But
in two key community mental health surveys—the National Institute of
Mental Health Epidemiologic Catchment Area Program and the National
Comorbidity Survey—the criterion has undergone a potentially crucial
modification, he said.
For symptoms to meet diagnostic criteria, the Diagnostic Interview Schedule
(used in the Epidemiologic Catchment Area study) and the revised Composite
International Diagnostic interview (used in the National Comorbidity Survey)
required that symptoms be associated with either reports of consulting a
physician or other medical professional or interference in the respondent's
everyday activities.
The two surveys have served as the authoritative sources for estimates of
mental health treatment need in the United States.
In the analysis of data from the National Health Interview Survey, the
researchers found that rates of depression among African Americans, compared
with those for whites, differed markedly depending on whether symptoms only
were reported or whether receipt of care and/or interference with life
activities was reported.
In the report of symptoms alone, there was virtually no difference in the
rates of depression among blacks and whites, with 4.08 percent of African
Americans and 4.62 percent of whites reporting symptoms.
But when receipt of care was added as a criterion, depression was indicated
in only 1.74 percent of African Americans compared with 2.86 percent of
whites. Likewise, when impairment in functioning was added as a criterion,
just 1.69 percent of African Americans reported depression compared with 2.18
percent of whites.
The National Health Interview Survey is conducted annually by the National
center for Health Statistics, part of the Centers for Disease Control and
Prevention, and is the major data-collection instrument used to assess the
general health of the U.S. resident, civilian, noninstitutionalized
population. It surveys a nationally representative sample of households, which
in 1999 consisted of 30,801 adults interviewed in their homes by trained
interviewers from the U.S. Bureau of the Census.
The 1999 survey instrument included the depression module of the Composite
International Diagnostic Interview-Short Form.
"We are quite surprised by the strength of our finding that if you
ask people in the community about symptoms of depression, you don't find
differences between African Americans and whites," Coyne told
Psychiatric News. "However, if you require that they be in
treatment or that they consider their depression a source of impairment, it's
quite a drop-off. This could be a real glitch in our efforts to estimate unmet
needs in the community."
Coyne is a professor of psychology in psychiatry at the University of
Pennsylvania School of Medicine.
Coyne said the tendency among African Americans not to report receipt of
care may stem from lack of access to care. And he added that qualitative
research in African-American communities suggests that many black people who
report depressive symptoms are liable to attribute those symptoms not to a
condition that can be treated and ameliorated, but to life
circumstances—lack of employment, lack of money, and other
hardships.
"This could be a real glitch in our efforts to estimate unmet
needs in the community."
"Our qualitative interviews show that African Americans often have a
preference for trying to work out their problems on their own, and that they
want to feel they have exhausted that," he said. "If a physician
were to tell them they were depressed, they would be just as accepting of that
and would understand the diagnosis. But there seems to be a gap between saying
`I have depression and I know what it means' and seeking treatment.
"They are more likely to say, `I have a lot of problems in my life,
and that's why I am depressed.' "
He said the phenomenon is similar to one observed among cancer patients who
report symptoms of depression but typically attribute them to their disease,
and for that reason they consider the depression something that is not
amenable to treatment.
"Health Disparities in Care for Depression Possibly Obscured
by the Clinical Significance Criterion" is posted at
<http://ajp.psychiatryonline.org/cgi/content/full/163/9/1577>.
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