Undertreatment Of Depression Research Articles

A Hypothesis of Gender Differences in Self-Reporting Symptom of Depression: Implications to Solve Under-Diagnosis and Under-Treatment of Depression in Males.

The phenomenon of female preponderance in depression has been well-reported, which has been challenged by higher rates of suicide and addictive behaviors in males, and a longer life-span in females. We thus propose an alternative hypothesis “Gender differences in self-reporting symptom of depression,” suggesting mild-moderate depression tends to be reported more often by females, and severe depression and suicide tend to be reported more often by males. Potential mechanisms that account for this difference may include three aspects: covariation between estrogen levels and the incidence peak of female depression, gender differences in coping style (e.g., comparative emotional inexpressiveness and non-help-seeking in males), and gender differences in symptom phenotypes (e.g., atypical symptoms in male depression). Our newly presented hypothesis implied the overlooked under-diagnosis and under-treatment of depression in males. For effective diagnoses and timely treatment of male depression, it is critical to incorporate symptoms of depression in males into the relevant diagnostic criteria, encourage males to express negative emotions, and increase awareness of suicidal behavior in males.

Youth Suicides Increased After FDA Required Antidepressant Warnings

Back to table of contents Previous article Next article Clinical & ResearchFull AccessYouth Suicides Increased After FDA Required Antidepressant WarningsTerri D'ArrigoTerri D'ArrigoSearch for more papers by this authorPublished Online:1 Dec 2020https://doi.org/10.1176/appi.pn.2020.11b31AbstractDepression diagnoses and treatment declined in the wake of the FDA warnings, disrupting a previously downward trend in suicide among adolescents and young adults.Suicide deaths among adolescents and young adults increased after the U.S. Food and Drug Administration (FDA) issued warnings about antidepressant use and possible suicidal ideation in these populations, a study in Psychiatric Research and Clinical Practice has found. The researchers buttressed their findings by including results from more than a decade of prior research suggesting that the warnings also reduced care seeking, depression diagnoses, psychotherapy visits, antidepressant treatment, and monitoring of patients who take antidepressants and may have led to increased suicide attempts.The FDA should consider downgrading its warnings about antidepressants and suicidal ideation in adolescents and young adults, says Stephen B. Soumerai, Sc.D.Harvard Pilgrim Health Care Institute/Elisif Andrews Brandon“It is surprising that a warning could set off a chain of events that are important intermediate outcomes in health care that could influence suicide,” senior author Stephen B. Soumerai, Sc.D., a professor of population medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute, told Psychiatric News. “The warnings had unintended consequences of fear and stigma, not just among youth but among parents and clinicians.”Soumerai and colleagues analyzed data on suicide deaths by people aged 10 to 24 years from the Centers for Disease Control and Prevention’s WONDER database, which contains mortality counts for U.S. residents based on birth certificates. They analyzed suicide rates for the following three time segments:1990 to 2002, a 13-year span before the FDA issued its first warning, a public health advisory that children and adolescents who took antidepressants were at increased risk of suicidal ideation and behavior2003 and 2004 as a transition period after the initial advisory2005 to 2017, after the FDA required a boxed warning, effective in January 2005, for children and adolescents taking antidepressants, a warning that was expanded to include young adults in 2007Before the warnings, suicide deaths in youth had been on a downward trend. From 1990 to 2002, suicide deaths among adolescents aged 10 to 19 years dropped from 6.4 to 4.2 per 100,000 per year. For the same time frame, suicide deaths had decreased in young adults aged 20 to 24 years from 15.1 to 12.3 per 100,000 per year.However, almost immediately after the FDA issued its first black-box warning on antidepressants, depression care began to decline and suicide deaths began to climb in both groups. Between 2005 and 2017, suicide deaths among adolescents rose from 4.4 to 7.2 per 100,000 people a year. At the same time, suicide deaths among young adults rose from 12.4 to 17.0 per 100,000 people a year.“A mechanism for this association is clear: The FDA antidepressant ‘warning,’ accompanied by exaggerated media coverage, stigmatized depression care for young people and fostered reluctance by providers to initiate antidepressant treatment. Thus, the warnings reduced diagnosis of major depression and drug and nondrug mental health treatment,” the researchers wrote.“Not all young people with depression should be treated with medication. Research demonstrates that many will do well with structured forms of therapy such as CBT [cognitive-behavioral therapy],” said David Fassler, M.D., a clinical professor of psychiatry at the University of Vermont’s Larner College of Medicine, who was not involved in the research. “The real tragedy is that following the black-box warnings and the related media coverage, so many adolescents and young adults received no treatment at all.“This [study] represents a significant contribution to the ongoing dialogue concerning the impact of the FDA’s black-box warnings,” Fassler added. “Hopefully, it will help inform clinical practice, public policy, and future research initiatives.”Soumerai believes that the FDA should consider downgrading its warnings on antidepressants.“At the very least, take them out of the box,” he said. “We’re not saying these drugs don’t have the potential to harm. All drugs have the potential to harm if they are used inappropriately. Antibiotics have significant risks. Nonsteroidal anti-inflammatory medications can put people with certain risk factors into kidney dialysis. But undertreatment of depression can be harmful [and] result in suicidal behaviors and death.”Several of the researchers were supported in part by a cooperative agreement with the National Institute of Mental Health. ■“Increases in Suicide Deaths Among Adolescents and Young Adults Following U.S. Food and Drug Administration Boxed Warnings and Declines in Depression Care” is posted here. ISSUES NewArchived

A collaborative care psychosocial intervention to improve late life depression in socioeconomically deprived areas of Guarulhos, Brazil: the PROACTIVE cluster randomised controlled trial protocol

BackgroundThe elderly population has been growing in most low- and middle-income countries (LMIC), and depression is a common condition among these populations. The lack of integration between mental health and primary healthcare services and the shortage of mental health specialists in the public health system contribute to underdiagnosis and undertreatment of depression. One of the strategies to reduce this gap is task shifting and collaborative care treatments. This study therefore aims to evaluate the effectiveness and cost-effectiveness of a collaborative care psychosocial intervention to improve the clinical management of depression among elderly people in poor neighbourhoods in Guarulhos, Brazil.MethodsTwo-arm, cluster randomised controlled trial with Basic Health Units as the clusters and a 1:1 allocation ratio. Twenty Basic Health Units have been randomly selected and randomised to control or intervention arms. We aim to recruit 1440 adults (72 per cluster) aged 60 years or over identified with depression (9-item Patient Health Questionnaire (PHQ-9) score ≥ 10). The control arm participants will receive an enhanced usual care, while the intervention arm participants will receive an enhanced usual care and a 17-week psychosocial intervention programme delivered at home by community health workers with the help of an application installed on tablet computers. The primary outcome is the proportion with depression recovery (PHQ-9 < 10) at 8 months’ follow-up. We will also assess the maintenance of any earlier clinical gains and the cost-effectiveness of the intervention at 12 months.DiscussionThis is the first randomised trial to investigate a collaborative care intervention to treat depression among poor elderly in LMIC/Latin America. This is a major public health problem worldwide, but in these countries, there are no locally tested, evidence-based interventions available to date.Trial registrationInternational Standard Randomised Controlled Trial Number ISRCTN57805470. Registered on 25 April 2019

Making sense of sadness: eliciting illness meaning and experience of depression in rural Irish males

BackgroundTo analyse and understand the illness experience of depression in rural Irish males. Secondary objectives are to identify their explanatory models of depression, inform mental health service provision in rural areas, and identify suitable interventions for future research.AimIsolation and rural masculinities are thought to predispose rural Irish males to depression. Despite high levels of depressive symptoms among men in rural areas, lack of awareness and a different language around depression, coupled with stoicism, social isolation, and feminized mental health services, results in reduced help-seeking, under-reporting and under-treatment of depression in this population.MethodA purposive sample, selected through the West Cork and Galway/Roscommon Mental Health Services, and General Practitioners, of fourteen men, aged between 25 and 64 years of age, were interviewed in their homes. Data was collected through face-to-face interviews, using the McGill Illness Narrative Interview schedule. These interviews were recorded, transcribed to text, and analysed using a thematic content analysis. Results were integrated using the model of qualitative description.ResultsMost of the fourteen men reported alcohol and social isolation as precipitating factors of their depression. Suicidal intent and a stubborn attitude were common. Recovery-promoting behaviours included good social and family support, peer-support groups, religious practice and, universally, physical work.ConclusionRural Irish men view their depression as a disconnection from community, masculinity can be engaged in a positive way to improve mental health, and a sense of belonging is key to recovery. Future research should focus on the development of interventions incorporating these findings, such as community farming initiatives.

The Use of Internet-Enabled Cognitive Behavioral Therapy in the Treatment of Depression and Anxiety amongst Older People

This article reports on the experience of internet-enabled cognitive behavioural therapy (IECBT) for older people diagnosed with depression and anxiety. IECBT involves synchronous real-time communication between the therapist and patient via instant messaging and has been found to be effective in the treatment of patients over eighteen diagnosed with depression. While younger populations are an obvious focus for studies into the potential of internet-based therapies, older people’s experience of such therapies can be overlooked due to assumptions about their relatively lower rates of internet use. However, rapid increases in this generation’s levels of internet access make this an important avenue of enquiry. In addition, such therapies may offer a route to address the underdiagnosis and undertreatment of depression and anxiety among older people. Once older people are diagnosed, evidence suggests that they tend to prefer psychological therapies, and these can be effective in this age group. This article therefore builds on the positive findings about IECBT as a treatment option in general by, for the first time, analysing quantitative data relating to older people’s use of this form of therapy. It analyses secondary data on patient characteristics, take-up of treatment, and treatment outcomes, finding that older men are over-represented among IECBT patients and that rates of self-referral are higher in this age group.

EPA-0972 – Optimising suicide prevention programmes and their implementation in europe (OSPI-europe): results on suicidal behaviour

Ulrich Hegerl and the EAAD members A variety of factors such as undertreatment of depression and other psychiatric disorders, access to lethal means, media coverage of suicidal acts, stigmatisation of patients with mental disorders and alcohol consumption contribute to the high numbers of completed and attempted suicides in Europe. The 4-level-intervention concept developed within the model project’Nuremberg Alliance against Depression’ provided evidence for the efficiency of an intervention approach targeting simultaneously several of the above mentioned factors (1). Up to now, similar 4- level interventions have been implemented in more than 100 regions in Europe (2). This was done via large EU-funded projects, namely the’European Alliance against Depression’ (EAAD; www.eaad.net ) and OSPI-Europe ( www.OSPI-europe.com ; 7 th Framework Programme ). From these projects data on suicidal behaviour during interventions in comparison to baseline and control regions (3) and on process evaluation will be presented. Via the EAAD, the intervention concept, the intervention materials and the broad experiences with the implementation of 4-level interventions in different cultures are offered to interested regions in and outside of Europe.

Depression and Undertreatment of Depression: Potential Risks and Outcomes in Black Patients with Lung Cancer

In the United States, Black men are at higher risk than White men for lung cancer mortality whereas rates are comparable between Black and White women. This article draws from empirical work in lung cancer, mental health, and health disparities to highlight that race and depression may overlap in predicting lower treatment access and utilization and poorer quality of life among patients. Racial barriers to depression identification and treatment in the general population may compound these risks. Prospective data are needed to examine whether depression plays a role in racial disparities in lung cancer outcomes.

Racial Disparities in Depression Care among Older Adults: Can the Perspectives of Clinicians and Patients be Reconciled?

Depression is highly prevalent and debilitating in late life. It affected 3.8 million older Americans in 2005, and its prevalence is expected to increase to 6.6 million in 2025. Despite its prevalence and associated negative health outcomes, depression is not diagnosed and treated equally among older Americans. An under-recognition and under-treatment of depression in minority elders exists, which has lead to significant disparities between Whites and non-Whites. These disparities challenge our principles of equality, equity and adequacy and, in their most extreme form, become human rights issues. As a result, eliminating health disparities has become a priority of the US Federal government. Practitioners must address differences in the diagnosis and treatment of depression among clients served. Increased levels of cultural competency and educating clients will help reconcile differences between clinicians and their patients and lead to increased understanding of client needs, while decreasing disparities in depression care and diagnosis.

Ethics Commentary: Ethical Issues in Geriatric Psychiatry

By 2030, due to the aging of the baby boomers, the U.S. Census Bureau predicts that nearly one in five people will be 65 or older—a substantial increase from the 13% of the population that was 65 or older in 2010. This population of older adults is projected to have increased needs for mental health care, which the current workforce is inadequate to meet (1, 2). For example, by the year 2050, an estimated 13 million adults will suffer from Alzheimer’s disease (AD) (3). Many of these individuals will develop behavioral and psychological symptoms as their disease progresses. Depressive disorders remain underdetected in older adults, and despite years of attention to the issue of undertreatment of depression in the older adult population, this continues to be a problem (1, 4). Ongoing stigma about mental health treatment on the part of patients, as well as misconceptions and inadequate training regarding depression on the part of health care providers, likely contribute to the lack of identification and treatment of depressive disorders in older adults (5). Thus, although many older adults will age “successfully,” with intact cognition and stable mental health, a substantial minority will experience new onset psychiatric disorders, recurrence of disorders that initially developed earlier in life, or psychiatric manifestations of neurologic and medical disorders and their treatment. Special ethical challenges emerge at the intersection of aging, comorbidmedical illnesses, and psychiatric illnesses. Although a complete discussion of these issues is beyond the scope of this column, two topics that have received relatively little attention in the literature—financial exploitation and ethical issues in hospice care for patients with psychiatric disorders—will be discussed through the use of case examples.

Racial Differences in Antidepressant Use Among Older Home Health Care Patients

The objective of this study was to determine the association of race (black and white) with depression diagnosis and antidepressant use among older home health care patients. Cross-sectional data were obtained from the 2007 National Home and Hospice Care Survey of patients 65 years and older (N=3,157). Data were analyzed by race, antidepressant use, and charted depression diagnosis. Whites had greater odds than blacks of receiving a depression diagnosis (adjusted odds ratio [AOR]=4.46, 95% confidence interval [CI]=1.52-13.09). Whites with no depression diagnosis were also more likely to receive an antidepressant (AOR=2.62, CI=1.58-4.36); however, the difference in receipt of an antidepressant between whites and blacks with a depression diagnosis was not significant. Older blacks were less likely than older whites to receive antidepressants, independent of a depression diagnosis. This finding suggests that older blacks with depression in home health care may face two disparities relative to whites: underdiagnosis and undertreatment of depression.

Late-Life Depression in Home Healthcare.

Major depression is disproportionately common among elderly adults receiving home healthcare and is characterized by greater medical illness, functional impairment, and pain. Depression is persistent in this population and is associated with numerous poor outcomes such as increased risk of hospitalization, injury-producing falls, and higher health care costs. Despite the need for mental health care in these patients, significant barriers unique to the home healthcare setting contribute to under-detection and under-treatment of depression. Intervention models target the home healthcare nurse as liaison between patients and physicians, and instruct in the identification and management of depression for their patients. Successful implementation requires interventions that 'fit' how home healthcare is organized and practiced, and long distance implementation strategies are required to increase the reach of these interventions.

Association between race, depression, and antiretroviral therapy adherence in a low-income population with HIV infection.

Racial disparities exist in many aspects of HIV/AIDS. Comorbid depression adds to the complexity of disease management. However, prior research does not clearly show an association between race and antiretroviral therapy (ART) adherence, or depression and adherence. It is also not known whether the co-existence of depression modifies any racial differences that may exist. To examine racial differences in ART adherence and whether the presence of comorbid depression moderates these differences among Medicaid-enrolled HIV-infected patients. Retrospective cohort study. Multi-state Medicaid database (Thomson Reuters MarketScan®). Data for 7,034 HIV-infected patients with at least two months of antiretroviral drug claims between 2003 and 2007 were assessed. Antiretroviral therapy adherence (90 % days covered) were measured for a 12-month period. The main independent variables of interest were race and depression. Other covariates included patient variables, clinical variables (comorbidity and disease severity), and therapy-related variables. In this study sample, over 66 % of patients were of black race, and almost 50 % experienced depression during the study period. A significantly higher portion of non-black patients were able to achieve optimal adherence (≥90 %) compared to black patients (38.6 % vs. 28.7 %, p < 0.001). In fact, black patients had nearly 30 % decreased odds of being optimally adherent to antiretroviral drugs compared to non-black patients (OR = 0.70, 95 % CI: 0.63-0.78), and was unchanged regard less of whether the patient had depression. Antidepressant treatment nearly doubled the odds of optimal ART adherence among patients with depression (OR = 1.92, 95 % CI: 1.12-3.29). Black race was significantly associated with worse ART adherence, which was not modified by the presence of depression. Under-diagnosis and under-treatment of depression may hinder ART adherence among HIV-infected patients of all races.

Under-treatment of depression in older persons

Due to the cross-sectional design of most existing studies, longitudinal characterization of treatment for depression in older persons is largely unknown. Seven hundred fifty-four men and women (aged 70+ years) underwent monthly assessments of mental health professional use and 18-month assessments of antidepressant medication use and depressive symptoms over 9 years. Scores of ≥20 on the Center for Epidemiological Studies-Depression (CES-D) scale denoted depression. We evaluated trends in depression treatment over time in the entire sample and among the depressed participants. Using generalized linear models, we determined characteristics associated with receiving treatment for depression in these groups and among those with persistent depression. During the 9-year follow-up period (1998-2007), 339 (45.0%) of the participants reported depression treatment. Over time, antidepressant use alone decreased (p trend<0.001) while treatment with both antidepressants and a mental health professional increased (p trend=0.002). Of the 286 (27.9%) depressed participants, between 43% and 69% did not receive depression treatment during any 18-month interval. 30.5% of the 121 participants with persistent depression did not receive treatment during the study period. Increasing number of years of education, decreasing cognitive status score, and being physically frail were associated with a higher likelihood of receiving treatment in all models. Pre-baseline depression, pre-baseline treatment, and indication for treatment were unavailable. Our findings indicate that the profile of treatment for depression in older persons has changed over time, that depressed older persons, including those with persistent depression, are under-treated, and that patient characteristics influence receipt of treatment.

Underdiagnosis and undertreatment of depression in nursing home residents

Background Depression in nursing home residents decreases their quality of life and is related to behavioral symptoms of dementia. Diagnosing depression in patients with advanced cognitive impairment may be challenging. The purpose of this study was to find out how well depression is diagnosed and treated in Dutch nursing homes in relation with age and dementia severity. Methods This cross-sectional study evaluated diagnoses and treatment of depression in nursing home residents using Minimum Data Set (MDS) information. Clinical and MDS-based diagnoses of depression were compared in 1851 residents of eight Dutch nursing homes and their medication use was analyzed. Results A clinical diagnosis of depression was present in 14.4% of residents while 42.5% had an MDS diagnosis. This difference was mainly due to an increasing discrepancy between clinical and MDS diagnoses with increasing stage of cognitive impairment. Antidepressants were used only in 33.9% of residents with an MDS diagnosis of severe depression and were given less often to older subject with depression diagnosis. Symptoms of depression were present even in residents treated with antidepressants. Antipsychotics were given to 220 subjects and antianxiety medications to 100 subjects who were diagnosed with depression but were not treated with antidepressants. Conclusions Depression is underdiagnosed and undertreated, especially in nursing home residents with cognitive impairment. Some residents seem to be treated for depression with antipsychotics and antianxiety medications. More attention paid to recognition and treatment of depression can be expected to improve quality of life of many nursing home residents.

Physiciansʼ Decisions to Prescribe Antidepressant Therapy in Older Patients with Depression in a US Managed Care Plan

Published studies indicate that depression in older adults is severely under-recognized and under-treated. To characterize primary-care physicians' decisions to prescribe antidepressants to older patients with depression. Electronic medical record (EMR) notes from office visits of older patients (aged ≥65 years), treated in a central Massachusetts multi-specialty medical group practice, were screened every 2 weeks between August 2007 and July 2008 for mention of depression. Electronic surveys containing questions about depression severity and onset, and antidepressant treatment, were sent to physicians whose EMR notes indicated that they had treated an older patient with depression, until approximately 400 responses had been received. Physicians were asked about whether they prescribed antidepressants or made changes to antidepressant treatment and were asked about the extent to which they agreed with a set of pre-specified reasons for treatment recommendations. Physicians were also allowed to document any other reasons that influenced their decision. Patient characteristics and treatment were identified from administrative claims. Univariate analyses were used to describe patient characteristics and physician survey responses. Physicians responded to the survey and confirmed a depression diagnosis for 396 patients, for whom the average age was 77.1 years and 76.5% were female. Most patients had physician-reported depression onset after age 60 years (72.2%) and moderately severe depression (58.8%). Physicians reported that 62.9% of patients were already being treated with antidepressants prior to their visit, 28.5% were recommended antidepressant initiation and 8.6% were not prescribed antidepressants. Selective serotonin reuptake inhibitors were most frequently prescribed. Maintaining prior therapy was recommended for 81.1% of treated patients and treatment modification for 18.9%. Almost all physicians (>92%) agreed that experience in use of prescription drugs, safety/tolerability and patient improvement influenced their decision to maintain prior therapy or recommend new therapy. 85.8% of physicians agreed that availability of efficacy data in the elderly influenced their decision to prescribe new therapy. 38.9% of patients who were recommended new therapy initiation did not fill an antidepressant prescription. Despite previous reports of under-treatment of depression in the elderly, this study suggests that physicians are comfortable prescribing antidepressants to the elderly, and the majority of older patients with depression were prescribed antidepressants. Rather than a physician's prescribing decision, it may be patient factors, such as refusal to accept diagnosis/treatment and noncompliance, that may lead to under-treatment--approximately 40% of patients who were recommended new antidepressant therapy did not fill an antidepressant prescription.

Depression and Diabetes: More on What the Relationship Might Be

Depression and Diabetes: More on What the Relationship Might Be

Screening for depression in the older long-term unemployed

Misdiagnosis and undertreatment of depression in older, long-term unemployed people may not only pose a serious medical problem, but may also be an obstacle for their vocational reintegration. Screening for depression could be a first step to increasing treatment rates within this high-risk group. Therefore, the WHO-5 Well-Being Index was tested for its validity in unemployment offices. Three hundred and sixty-five participants in a German programme for the vocational reintegration of long-term unemployed people were screened with the WHO-5 Well-Being Index. In 104 of these subjects, ICD-10 diagnoses were made using DIA-X Structured Clinical Interview. Using the DIA-X data as a gold standard, the WHO-5 Well-Being Index obtained satisfactory results for sensitivity (82.5%) and specificity (70.3%) as a screening tool for affective disorders when used with an adjusted cut-off-point of < or = 12. While none of the 18.5% male participants diagnosed with major depression received treatment, half of the 24% of female participants with major depression received treatment. Screening with the WHO-5 within unemployment offices is useful to detect people with depressive disorders. Many of them do not receive optimal treatment and can be motivated to seek professional help. Reducing depression by better treatment will also increase the chances of reemployment.

A Patient Who Flags for ‘Depression’ Is Not Necessarily Depressed

A Patient Who Flags for ‘Depression’ Is Not Necessarily Depressed

Adequacy of continuation and maintenance treatments for major depression in Japan

Guidelines for treating depression often recommend continuing antidepressants at least for 6 months after remission. Whether this recommendation is implemented in daily practices represents a serious concern. We aimed to examine adequacy of continuation and maintenance treatment in Japan. A naturalistic prospective follow-up study with mood disorders was undertaken in 23 psychiatric departments from all over Japan. A total of 95 patients diagnosed with major depression were followed up every month until treatment termination and every 6 months thereafter. In this study, the cohort received 45.1 (SD = 64.7) mg of imipramine or equivalent per day during continuation phase, and about 74% were prescribed inadequate doses, i.e. less than 75 mg/day. At maintenance phase immediately before relapse, average dosage was 42.0 (SD = 74.7) mg/day and 83% were prescribed inadequate doses. There is gross under-treatment of depression during continuation and maintenance phases in Japan.

Antidepressant Treatment of Depression in Rural Nursing Home Residents

Under-diagnosis and under-treatment of depression are major problems in nursing home residents. The purpose of this study was to determine antidepressant use among nursing home residents who were diagnosed with depression using three different methods: (1) the Geriatric Depression Scale, (2) Minimum Data Set, and (3) primary care provider assessments. As one would expect, the odds of being treated with an antidepressant were about eight times higher for those diagnosed as depressed by the primary care provider compared to the Geriatric Depression Scale or the Minimum Data Set. Men were less likely to be diagnosed and treated with antidepressants by their primary care provider than women. Depression detected by nurses through the Minimum Data Set was treated at a lower rate with antidepressants, which generates issues related to interprofessional communication, nursing staff communication, and the need for geropsychiatric role models in nursing homes.