Blacks, Latinos Less Likely Treated For Depression
MICHEL MARTIN, host:
I'm Michel Martin, and this is TELL ME MORE from NPR News. Coming up, what I want to know about that alleged Christmas Day bomb attack. That's in just a few minutes.
But first, it's time to go Behind Closed Doors. That's our weekly conversation where we explore issues that are often kept hidden, often because of stigma or shame.
On this program, we've previously talked about the difficulty of treating dual disorders, both drug addiction and mental illness. Today, we want to talk about depression and race. A new study by the University of Michigan and Harvard University has found that Mexican-Americans and African-Americans are less likely to receive any type of therapy for their depression than members of other ethnic groups.
Joining now to talk about this is the lead author of the study, Hector Gonzalez. He's assistant professor of medicine at Wayne State University in Detroit - and Dr. Carl Bell, clinical professor of psychiatry and public health at the University of Illinois at Chicago. He's joined us from time to time to talk about other issues related to mental illness. I welcome you both. Thank you for joining us.
Professor HECTOR GONZALES (Medicine, Wayne State University): Thank you.
Dr. CARL BELL (Clinical Professor of Psychiatry and Public Health, University of Illinois at Chicago): Thank you, and it's a pleasure to be here.
MARTIN: Let me just set the table by asking if either of you believes that any group of Americans adequately receives treatment for depression. Dr. Bell, what about you?
Dr. BELL: Oh, no. The surgeon general report that Satcher did, the recent Institute of Medicine report that we've done on depression shows clearly out of the 20,000 - out of 100,000 people that get depressed, hardly anybody is getting adequate treatment for their depression.
MARTIN: Professor Gonzalez?
Prof. GONZALEZ: Well, that was the focus of our paper, and what we see is pretty much that, is that in the U.S., people who meet criteria for depression, major depression, only about one in five or 20 percent get some type of adequate - minimally adequate treatment, I'd add.
MARTIN: But what's in that? Professor Gonzalez, you found that ethnicity and race are important factors on whether people receive any treatment and what kind of treatment they receive. Would you just tell us more about what you found?
Prof. GONZALEZ: Sure. We started off with asking the question: So, how many people get any kind of treatment? And when you start there, you see that about half of the U.S. population who are depressed get some kind of treatment.
Then we asked, well, how many people are getting adequate treatment according to the American Psychiatric Association's guidelines for the treatment of depression? And that quickly falls down to about one in five or 20 percent.
Now, we were particularly interested in looking at ethnic racial minorities -not just black, Latino, white, but looking very carefully at different subgroups of ethnicities and race, if you will. And we see that about one in 10 or 10 percent of Mexican and African-Americans get an adequate level of depression care.
MARTIN: And why do you think that is?
Prof. GONZALEZ: Well, I think it speaks to a lot of things, and I think in particular is access that many ethnic and racial minorities may not have. When about 40 percent of the Mexican-Americans in the U.S. have health insurance -that is, Mexican-American adults - that's going to preclude you from going to get the care you might need.
MARTIN: So do you think it's primarily a matter of access to care?
Prof. GONZALEZ: We asked that question in the same study: Is it about insurance? And something that we already knew, that most Mexicans are not insured. And we see that it makes a little bit of a difference, but not a lot. It really didn't make much difference for African-Americans, we see.
MARTIN: Dr. Bell, what is your take on this? Why is that? Why do you think this disparity exists?
Dr. BELL: Well, there are a lot of reasons. If you look at African-American populations, they have never gotten the benefit of modern medical technology: heart transplants, kidney transplants. We just don't get those levels of services.
And partly, it's access. Partly, it's fear. Partly, for mental health, it's stigma. Partly, it's discrimination that's experienced when you go to a health care provider and they make stereotypic assumptions about who you are and how you are and what you're capable of.
There's also some evidence that, you know, different ethnic groups, different cultures, show symptoms differently. For example, European-American depressed adolescents, when they get in trouble with the law or get in trouble with school, that's sort of a symptom of their depression. But when you look at African-Americans, that is not as robust as a predictor of depression. So there are differences in different ethnic groups. It shows up differently. So there's a risk of misdiagnosis.
And in addition to all of that, there's a fairly strong push by some anti-psychiatrists to suggest to people of color that psychiatry is a profession that seeks to kill and they promulgate their propaganda, their negative psychiatry propaganda into minority communities, which may not be as sophisticated, and they believe this garbage that psychiatrists want to put everybody on antidepressant medication.
MARTIN: Professor Gonzalez, did you find in terms of access to pharmacology, using medicine to treat depression as opposed to psychotherapy using, if I could - can I use this term, talk therapy?
Prof. GONZALEZ: Sure.
MARTIN: Was there a difference?
Prof. GONZALEZ: Well, what we saw, and this was an interesting finding, is among people who are depressed, we see that psychotherapy's used more than pharmacotherapy or antidepressants, as they're more commonly called. That was a big surprise. And I think it makes sense too...
MARTIN: Yeah, I was going to ask, why do you think that is?
Prof. GONZALEZ: Well, only the very severe people - people who have very severe depression are responding to antidepressants beyond placebos. In our national estimates, that's only about 15 percent of the population of people who get depressed. What that means is that probably that other 85 percent are just probably dissatisfied with their treatment and not sticking with it in getting that adequate care that they need. Whereas, for the psychotherapy, maybe people are responding and sticking with it, seeing it through and getting the adequate level of treatment as we defined it as.
MARTIN: If you're just joining us, this is TELL ME MORE from NPR News. I'm speaking with Dr. Carl Bell of University of Illinois and Hector Gonzalez, a professor of medicine at Wayne State University. He's the author of a study about African-Americans and Mexican-Americans and how they are less likely to receive treatment for depression than other groups.
Professor Gonzalez, you know, one of the findings that really fascinated me is that, overall, more participants received psychotherapy than pharmacotherapy -we just talked about that - but that Puerto Rican and non-Latino whites reported the highest use of psychotherapy while Mexican-Americans, Caribbean blacks, and African-Americans reported the lowest use. So what do you think that says? What's that about?
Prof. GONZALEZ: Well, you're not the only one who is surprised. I fully expected the reference group or the non-Latino whites would be the dominant or primary users, have the best access. And again, we were surprised to see that Puerto Ricans had as high or higher levels of treatment use than whites, for example. And lest we think that's an anomaly, is that we have done other studies looking at just general medical care access that shows the same pattern, where Puerto Rican Americans have equal or often better access to a usual source of care than white Americans.
I think what that tells me, is that perhaps there's something to be - first is we have to ask the question: Is there a disparity among Puerto Ricans compared to whites? And I think so far our evidence says no. And then, secondly, as a scientist - a health scientist, is ask the question: Well, what are they doing right that other groups might be able to take advantage of?
MARTIN: Any idea?
Prof. GONZALEZ: I think if you look carefully at workforce issues, the workforce - health care workforce of African-American, Mexican-American physicians, health care people are really low, whereas, Latinos make up 15 percent of the U.S. population, will make up a third of the U.S. population by 2050. Currently, less than five percent of MD's specifically are Mexican-American, just a little bit higher for African-Americans. Now, whether or not Puerto Ricans make up a larger group of MD's, that's a reasonable question to test out.
MARTIN: Dr. Bell, what do you think about that?
Dr. BELL: Well, I think part of what happens is that you get a lot of foreign medical graduates from Latino countries that come into the U.S., so that increases some of the availability. You do not see the same number of African medical graduates coming into the U.S., that's one issue. Another issue is context. There are a fair number of Puerto Ricans in New York City and even though this was a 48-state study, in New York there are Ph.D. psychologists and social workers falling off the trees because it's just a, you know, it's an urban kind of environment that has a lot of schools.
One of the important things about the study, which I'm glad to start seeing coming out, is that we are now sophisticated enough to be able to differentiate subgroups of Latinos, subgroups of African-Americans, Africans, Caribbean-Americans, subgroups of Chinese, because when we did Dr. Satcher's Culture and Ethnicity report back in 2001, we did not have this level of data in this sophisticated a way. So this is a very key piece to try to tease out some of these issues to fix them.
MARTIN: Professor Gonzalez, I take your point that, you know, oftentimes that we don't study what's working right so we can replicate it. What else would you like to pursue in this area?
Prof. GONZALEZ: I think for us at this stage, we are just at the infantile stage, if you will, of looking at these sub-ethnicities. This is new information. I think Dr. Bell has emphasized this. And to me, as a Latino, Mexican-American investigator, it's just being steeped and growing up in the culture where you just know that all Latinos are not the same. And to lump them together is an error.
MARTIN: Dr. Bell?
Dr. BELL: Well, the other thing I want to highlight is that we just completed a national research council as to the medicine report on prevention of behavioral disorders, substance abuse and problem behaviors in youth, adolescents and young adults and it turns out that depression can actually be prevented. We just completed a couple of studies on the use of the Internet to prevent depression by strengthening families and individuals and cultivating their resiliency.
So I think the next thing we've got to do as we tease out these different ethnic groups is we've got to try to make sure that these different culture and ethnic groups get the advantage of some of the prevention science that's coming out. So I'm looking for that in the future as we try to move forward with some health care reform.
MARTIN: Finally, before I let each of you go, I'm curious, if you don't mind my asking, each of you is a man of color...
Dr. BELL: Yes.
MARTIN: And each of you comes from a group that is represented as the most underserved groups, and I'd like to ask each of you how you decided to come into this field, into the field of psychiatry. And Dr. Bell, do you mind if I ask?
Dr. BELL: No. I don't mind. It's very clear to me, one of the things we're trying convince people of is that risk factors, whatever those risk factors are - growing up poor, growing up in drug-infested environments, poor schools -risk factors are not automatically predictive of a bad outcome because of protective factors - technology, medication, psychotherapy, strong church, strong family. So we've got to shift the paradigm of medicine from an illness care system to a wellness care system and that's what excites me and why I do public health as well as psychiatry. Because, you know, behavior is complex and it generates a lot of behavior and I want to save lives and make a difference.
MARTIN: Professor Gonzalez, what about you? What drew you to this field?
Prof. GONZALEZ: Well, I was drawn into clinical work initially, and I thought I'd make a happy life serving as a clinician, but - serving largely Mexican-American underserved populations. And it became apparent like within the first days in the clinic that the type of clinical care that was available to Mexican-Americans primarily was really off.
Misdiagnosis, I'd seen many people with misdiagnoses because probably language differences or cultural differences. And so I realized that there was a lot of work to do. Now fortunately, I had a good mentor and he said to me is that, you know, our clinical work is useful and valuable in serving our individual patients. And I still believe that and so I carry that deep inside as a kind of a driving force towards public health and psychiatry.
MARTIN: Well, thank you both for being with us. Hector Gonzalez is an assistant professor of medicine at Wayne State University in Detroit. He joined us from his offices there. Dr. Carl Bell is a clinical professor of psychiatry and public health at the University of Illinois at Chicago. He has been kind enough to join us from time to time to talk about important matters about mental illness and mental health and he joined us from Chicago Public Radio.
I thank you both so much for speaking with us.
Dr. BELL: Thank you.
Prof. GONZALEZ: It was a pleasure. Thank you.
MARTIN: Remember, at TELL ME MORE, the conversation never ends. And now we'd like to hear from you. Have you seen this phenomenon playing out in your own life or in your own family or community: psychologists, psychiatrists, other mental health professionals avoided on cultural grounds?
To tell us more, call our comment line at 202-842-3522. Again, that's 202-842-3522. Or you can go to our Web site. Just go to the new NPR.org, click on the TELL ME MORE page and blog it out.
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