To the Editor: I applaud the work of Alegría and colleagues described in their article, "Disparity in Depression Treatment Among Racial and Ethnic Minority Populations in the United States," in the November 2008 issue (1). In examining whether individuals who could benefit from depression treatment received no treatment or inadequate treatment, these investigators touched on an important policy issue that warrants further discussion. Namely, given the lack of population-based studies that take an expanded look at issues related to depression, what are some of the lessons that health professionals in the policy and research arena can learn from their findings? In terms of population health, one lesson is that we may need to broaden the focus from using a single indicator to using multiple indicators to improve the detection of the need for mental health care and the assessment of the quality of mental health care.
The Behavioral Risk Factor Surveillance System (BRFSS), conducted by the Centers for Disease Control and Prevention, is arguably the largest annual telephone health survey in the world. The BRFSS contains one general item related to the number of days in which the respondents rated their mental health as not good. In addition, eight items related to the severity of depressive symptoms are included in a list of optional questions, which means that states can elect not to include these items in their surveys. Although the eight optional questions measure some of the aspects of global functioning that are addressed in most depression scales, none of the BRFSS questions specifically ask for information related to the number of days in which respondents felt totally unable to carry out daily activities. In the study by Alegría and colleagues this variable was associated with the strongest likelihood of receipt of depression treatment and of receipt of adequate depression treatment. The strength of this association was second only to that of insurance type. In addition, none of the BRFSS questions attempt to look at the frequency or quality of depression treatment.
Our awareness of mental health care disparities is not new. The continued call by the Healthy People 2010 initiative to reduce racial and ethnic disparities in mental health care requires us to seriously reevaluate how we approach the identification of mental health care need in a racially and ethnically diverse society and how we measure the quality of that care as a way to engage and retain people in treatment. In a society that is increasingly more diverse, health policy makers and researchers must recognize the need to be sensitive and flexible in the use of language that is understandable to patients (2) and that recognizes how the expression of depression and depressive symptoms may be culturally shaped (3).
Mr. Lee is an independent researcher who is also affiliated with the California Department of Public Health, Sacramento. The views expressed are those of the author and may not necessarily represent the policies of the California Department of Public Health.
Alegría M, Chatterji P, Wells K, et al: Disparities in depression treatment among racial and ethnic minority populations in the United States. Psychiatric Services 59: 1264–1272, 2008
Lee DT, Kleinman J, Kleinman A: Rethinking depression: an ethnographic study of the experiences of depression among Chinese. Harvard Review of Psychiatry 15:1–8, 2007
Yeung A, Yu, SC, Fung F, et al: Recognizing and engaging depressed Chinese Americans in treatment in a primary care setting. International Journal of Geriatric Psychiatry 21:819–823, 2006