RESEARCH AND PRACTICE
Racial and Ethnic Disparities in Depression Care in
Community-Dwelling Elderly in the United States
Ayse Akincigil, PhD, Mark Olfson, MD, Michele Siegel, PhD, Karen A. Zurlo, PhD, James T. Walkup, PhD, and Stephen Crystal, PhD
Depression is a signicant public health con-
cern for older Americans.1 It has been estimated
that 6.6% of older Americans experience an
episode of major depression during 1 year.2 If
untreated or undertreated, depression can sig-
nicantly diminish quality of life3 and increase
mortality.4 Depression can complicate several
comorbid general medical conditions that are
common in older populations, including conges-
tive heart failure,5,6 diabetes,7 and arthritis.8
Antidepressant treatment and psychotherapy
have been shown to be effective in increasing
rates of remission for depression in older adults.9
Several studies during the 1990s identied
racial/ethnic differences in the diagnosis and
treatment of depression, both in the general
adult population and among the elderly.10---14
Although there was a general increase in rates of
depression diagnosis and antidepressant use
during this period, some studies suggest that
these increases are not consistent across racial/
ethnic subgroups15 and that disparities in the
treatment of diagnosed depression are persis-
tent.10,16,17
More recent studies (often combining the
nonelderly and elderly adult population rather
than considering these groups separately) have
provided mixed ndings. Some evidence in-
dicates that minority group members with de-
pression continue to receive less mental health
care than do non-Hispanic Whites, and some
studies suggest that mental health treatment
differences by race/ethnicity may have wors-
ened in the early 2000s.18---21 By contrast, 1
recent national study reported that although
overall increases in treatment rates were modest
in the 2000s, there were signicant increases in
treatment rates among African Americans, pos-
sibly narrowing the racial/ethnic gap among
adults in general.22 However, this study did not
examine disparities in treatment separately
among older adults and was founded on house-
hold reported conditions that are only modestly
related to provider diagnoses.23 The pattern of
diffusion of depression treatment may differ
February 2012, Vol 102, No. 2 | American Journal of Public Health
Objectives. We investigated racial/ethnic disparities in the diagnosis and
treatment of depression among community-dwelling elderly.
Methods. We performed a secondary analysis of Medicare Current Beneficiary
Survey data (n = 33 708) for 2001 through 2005. We estimated logistic regression
models to assess the association of race/ethnicity with the probability of being
diagnosed and treated for depression with either antidepressant medication or
psychotherapy.
Results. Depression diagnosis rates were 6.4% for non-Hispanic Whites, 4.2%
for African Americans, 7.2% for Hispanics, and 3.8% for others. After we adjusted
for a range of covariates including a 2-item depression screener, we found that
African Americans were significantly less likely to receive a depression diagnosis
from a health care provider (adjusted odds ratio [AOR] = 0.53; 95% confidence
interval [CI] = 0.41, 0.69) than were non-Hispanic Whites; those diagnosed were
less likely to be treated for depression (AOR = 0.45; 95% CI = 0.30, 0.66).
Conclusions. Among elderly Medicare beneficiaries, significant racial/ethnic
differences exist in the diagnosis and treatment of depression. Vigorous clinical
and public health initiatives are needed to address this persisting disparity in
care. (Am J Public Health. 2012;102:319328. doi:10.2105/AJPH.2011.300349)
between elderly and nonelderly adults. Conse- information from beneciary interviews and
quently, racial/ethnic differences in diagnosis Medicare claims for a nationally representative
and treatment among the elderly remain a po- sample of Medicare beneciaries, including
tentially important public health concern. those living in long-term care facilities. Bene-
We investigated whether there are racial/ ciary surveys are conducted at 4-month in-
ethnic differences (1) in the rate of diagnosis of tervals. Respondents are sampled from the
depression among the elderly, controlling for Medicare enrollment le. The sample is strati-
sociodemographic characteristics and depres- ed by age (< 45, 45---64, 65---69, 70---74, 75---
sion symptoms (depressed mood and anhedo- 79, 80---84, and 85 years) and drawn within
nia) reported on a 2-item screener; and (2) in zip codes designated as primary sampling units.
the treatment provided to those diagnosed with The oldest-old ( 85 years) and the disabled (
depression by a health care provider, adjusting 64 years) were oversampled to allow detailed
for these covariates. In a large, nationally analysis of these subpopulations. For commu-
representative sample, we examined whether nity dwellers (our study population), response
relationships between race/ethnicity and de- rates for initial interviews ranged from 80% to
pression diagnosis or depression treatment are 90%; once the rst interview was completed,
mediated by insurance coverage and perceived participation rates in subsequent rounds were
access to medical care, depression symptoms, > 95%. The survey includes questions on
and severity, or by other global measures of health care use and costs, health status, medical
health such as self-reported health status and and prescription drug insurance coverage, ac-
impairment in daily activities. cess to care, and use of services by benecia-
ries. Claims are only available for services
METHODS nanced through traditional indemnity plans
and are not available for services nanced
The Medicare Current Beneciary Survey by Medicare Managed Care plans; thus, our
(MCBS) is a 4-year rotating panel combining sample is restricted to the former.
Akincigil et al. | Peer Reviewed | Research and Practice | 319

Participants
Our study population included Medicare
beneciaries 65 years old and older. To stan-
dardize the observation period, we restricted
the sample for each year to respondents living
in the community for the entire year. We
excluded individuals who died, became eligible
for Medicare during the year, or were institu-
tionalized at some point during the year. We
excluded beneciaries with a diagnosis of bi-
polar disorder because appropriate treatment
strategies may differ for unipolar and bipolar
mood disorders.24 We also excluded enrollees
with missing data on either race/ethnicity or
depression symptom. The unit of analysis was
the person-year, and because MCBS is a rotating
panel, each person could contribute up to 3
observations to our analytic data set. This
resulted in a study sample of 12 353 unique
persons contributing 33 708 person-years of
observations between 2001 and 2005. The
sample was predominantly non-Hispanic White;
8.3% were African American, 1.9% were His-
panic, and 2.5% were non-Hispanic other.
Outcomes
An indicator variable for depression diag-
nosis describes whether the person had a med-
ical care claim during the observation year with
depression listed as a diagnosis. We conceptu-
alized treatment, our second outcome measure,
as receipt of either psychotherapy or antide-
pressant medications in the same observation
year. Medication containers and explanations
of benets are reviewed, and detailed data on
lled prescriptions are recorded during inter-
views. We identied antidepressant use from
those survey responses and psychotherapy
from the procedure codes indicated on the
Medicare claims for professional services. The
list of codes and drugs are available from the
corresponding author upon request.
Independent Variables
The conceptual framework developed by
Kilbourne et al. for advancing health dispar-
ities research within the health care system
guided us in identifying and organizing our
explanatory variables.25 Because there is
a growing consensus that groups other than
those dened by race/ethnicity are at risk for
being medically underserved, we controlled for
gender, age (young-old vs old-old), and rural
320 | Research and Practice | Peer Reviewed | Akincigil et al.
RESEARCH AND PRACTICE
residence (areas other than metropolitan statisti-
cal areas). Race/ethnicity was self-identied;
therefore, it reects the underlying cultural
perceptions and beliefs of the respondent.26
We also focused on the effect of key factors
that are potentially mutable (e.g., income, per-
ceived access to care, organization and nanc-
ing of health services such as availability of
medical insurance supplementing Medicare,
and quality of supplemental prescription drug
coverage). For single respondents, if personal
income was less than 150% of the federal
poverty line for a 1-person family, we catego-
rized the respondent as poor. We categorized
married respondents as poor if the couples
income was less than 150% of the federal
poverty line for a 2-person family. We catego-
rized supplemental insurance as Medicaid; all
other coverage (i.e., employer-sponsored or
self-purchased private insurance); or none. We
measured quality of supplemental prescription
coverage (none, limited, or comprehensive) by
the proportion of self-reported total prescrip-
tion drug costs that were paid out-of-pocket,
with less than 30% indicating comprehensive
coverage. We constructed perceived access to
care measures (nancial cost barrier, service
barrier, and dissatisfaction with care) using
established survey response patterns.27 We
dened nancial cost barriers as difculties
getting needed health care or seeing a doctor
because of 1 or more listed cost-related reasons.
Service barriers included trouble getting needed
health care because of a lack of transportation to
the doctor or hospital or difculty getting an
appointment; not seeing a doctor because the
enrollee could not get an appointment soon
enough, no doctor was available, or the enrollee
had no transportation; or dissatisfaction with the
waiting time, the location of the doctor, or the
paperwork. We classied enrollees as dissatised
with care if they were dissatised or very
dissatised with information about their diagno-
sis, quality of medical care received, doctors
concern for overall health, follow-up care after
initial treatment, time spent with the doctor, the
doctors thoroughness, the doctors attitude, or
the doctors competence.
Control Variables
Two questions on depression symptoms
were available in the survey. The rst question
assessed sadness and was worded as In the
American Journal of Public Health | February 2012, Vol 102, No. 2
past 12 months, how much of the time did you
feel sad, blue, or depressed? Possible re-
sponses included all the time (4), most of the
time (3), some of the time (2), a little of the time
(1), or none of the time (0). The second
question assessed anhedonia with a binary re-
sponse format and was worded as In the past
12 months, did you have 2 weeks or more
when you lost interest or pleasure in things that
you usually cared about or enjoyed? We
assigned a score of 2 to the presence of
anhedonia. Finally, we generated a depression
symptom score ranging from 0 (no symptom)
to 6 (sad all the time and lost interest in things).
We categorized scores lower than 4 as low
symptoms; 4 as medium; and 5 and 6 as high.
These questions were similar to a 2-item de-
pression screener (Patient Health Question-
naire or PHQ-2) with acceptable psychometric
properties.28 The PHQ-2 inquires about the
frequency of depressed mood and anhedonia
over the past 2 weeks, scoring each as 0 (not at
all) to 3 (nearly every day).
We controlled for measures of health, in-
cluding (1) self-reported health status (catego-
rized as excellent, very good, or good vs fair or
poor) and (2) impairment in activities of daily
living (ADL; bathing or showering, dressing,
eating, getting in and out of bed or a chair,
walking, and using the toilet) or instrumental
activities of daily living (IADL; using a tele-
phone, light housework, heavy housework,
preparing meals, shopping for personal items,
and managing money).
Statistical Methods
We computed Rao-Scott v2 statistics to test
for differences in the distribution of race/
ethnicity, diagnosis rates, and treatment rates
by explanatory variables (Table 1). In multi-
variate analyses, we estimated logistic regres-
sion models to assess the adjusted association
of each covariate with the probability of being
diagnosed and treated for depression (Table 2).
The MCBS sampling design is a multistage
probability sampling with 3 stages. The unit of
analysis was the person-year, and each person
could have contributed up to 3 observations to
the data set. We used the SURVEYFREQ and
SURVEYLOGISTIC procedures in SAS version
9.2 (SAS Institute, Cary, NC) to account for the
complex sampling design and the within-per-
son correlation across time. We weighted all
 TABLE 1Population Characteristics (Demographic, Socioeconomic, Coverage or Access, and Clinical Indicators) and Outcomes, Stratified by
Race/Ethnicity: Medicare Current Beneficiary Survey, United States, 20012005

Race/Ethnicity Outcomes
P b (Selected Depression Sample Size
Non-Hispanic African Non-Hispanic Two-Way Diagnosis With Depression Treatment Rates
Population Characteristics %a (No.) White, % American, % Hispanic, % or Other, % Comparisonsc) Rates, % Diagnosis, No. Among Diagnosed, %

All 100.0 (33 708) ... ... ... ... ... 6.20 2122 71.5
Race/Ethnicityd,e
Non-Hispanic White 87.3 (29 402) ... ... ... ... ... 6.43 1910 73.0
African American 8.3 (2875) ... ... ... ... ... 4.23 131 60.3
Hispanic 1.9 (656) ... ... ... ... ... 7.17 49 63.4
Non-Hispanic other 2.5 (775) ... ... ... ... ... 3.78 32 39.8
Genderd .009 (162; 1 = 3; 2 = 3; 1 = 4)
Men 43.3 (14 675) 43.9 38.4 43.4 40.4 3.88 597 69.3
Women 56.7 (19 033) 56.2 61.6 56.6 59.6 7.96 1525 72.3
Age .001 (162; 163; 263; 1 = 4)

February 2012, Vol 102, No. 2 | American Journal of Public Health

6574 48.6 (14 589) 48.2 53.3 38.1 54.7 6.03 891 74.3
7584 40.0 (13 904) 40.4 35.0 49.5 36.5 6.16 869 69.0
85 11.4 (5215) 11.4 11.8 12.4 8.9 7.03 362 68.9
Locatione < .001 (1 = 2; 163; 2 = 3; 164)
Nonmetro 27.1 (10 541) 28.4 22.2 10.1 10.2 6.29 661 67.6
Metro 72.9 (23 164) 71.6 77.9 89.9 89.7 6.16 1461 73.0
Educatione < .001 (162; 163; 263; 164)
No high school degree 29.1 (10 438) 25.3 54.7 72.5 43.1 6.61 683 67.0
High school graduate 36.5 (12 138) 38.4 24.1 16.9 25.7 6.28 781 72.0
RESEARCH AND PRACTICE

> high school 34.1 (11 014) 36.0 20.4 10.7 30.5 5.74 647 75.7
Incomed,e < .001 (162; 163; 263; 164)
< 150% below poverty line 32.3 (11 491) 27.7 60.4 78.4 63.2 7.14 821 67.2
150% below poverty line 67.7 (22 217) 72.3 39.7 21.7 36.8 5.75 1301 74.1
Supplemental health insuranced < .001 (162; 163; 263; 164)
Medicaid 12.2 (4335) 8.0 34.2 54.4 52.4 9.10 388 72.5
Other supplemental insurance 78.9 (26 347) 84.0 47.0 33.3 38.6 6.02 1615 71.9
None (Medicare only) 8.9 (3026) 7.9 18.8 12.3 9.0 3.75 119 63.5
Prescription coveraged,e < .001 (162; 163; 2 = 3; 164)
Comprehensive coverage 42.6 (14 186) 41.0 49.0 56.7 63.8 7.53 1072 77.4
Limited coverage 34.5 (11 635) 35.8 27.4 22.6 20.2 6.05 723 67.0
No coverage 19.0 (6626) 19.4 18.6 17.1 9.2 4.54 311 64.2

Continued

Akincigil et al. | Peer Reviewed | Research and Practice | 321

 TABLE 1Continued

Perceived access to care

Cost barrierd < .001 (162; 1 = 3; 2 = 3; 1 = 4)
No 94.7 (31 932) 94.9 92.2 93.2 94.4 6.06 1973 71.7
Yes 5.3 (1776) 5.1 7.8 6.8 5.6 8.52 149 69.2
Service availability barrierd .299
No 89.8 (30 316) 89.8 89.7 87.6 91.2 6.04 1853 71.0
Yes 10.2 (3392) 10.2 10.3 12.4 8.8 7.55 269 75.0
Dissatisfaction with cared < .001 (162; 163; 2 = 3; 1 = 4)
No 88.0 (29 664) 87.6 91.0 91.8 89.6 5.84 1759 71.2
Yes 12.0 (4044) 12.4 9.0 8.2 10.4 8.80 363 72.9
Clinical indicators
Self-reported health statusd < .001 (162; 163; 2 = 3; 164)
Fair or poor 20.6 (7222) 18.9 33.0 37.6 23.9 10.99 780 71.0
Excellent, very good, or good 79.2 (26 388) 80.8 66.8 62.4 75.8 4.94 1333 71.7

322 | Research and Practice | Peer Reviewed | Akincigil et al.

Average ADL impairment 0.70 0.52 (0.49, 0.55) 0.78 (0.70, 0.85) 0.95 (0.75, 1.14) 0.64 (0.51, 0.76) ... ... ... ...
Average IADL impairment 0.62 0.46 (0.43, 0.48) 0.68 (0.61, 0.75) 0.83 (0.68, 0.98) 0.60 (0.50, 0.70) ... ... ... ...
Depression symptomsd < .001 (1 = 2; 1 = 3; 263; 1 = 4)
Low 92.3 (31 012) 92.5 91.4 85.7 92.1 4.97 1574 71.0
Medium 5.0 (1742) 4.8 5.9 8.3 5.7 18.22 320 72.6
High 2.7 (954) 2.7 2.7 6.0 2.1 25.68 228 73.4
Diagnosis among subpopulation .585
diagnosed with depressione
Major depressive episode 23.4 (488) 27.1 24.4 31.1 26.0 ... 488 84.72
Other depression diagnosis 76.6 (1634) 72.9 75.6 68.9 74.0 ... 1634 67.49
RESEARCH AND PRACTICE

Note. ADL = activities of daily living; IADL = instrumental activities of daily living. We treated ADL and IADL as continuous variables, thus reported values are means with 95% confidence intervals.
a
Percentages are weighted and therefore reflect national estimates. Subsample sizes may not add up to 33 708 as a result of missing data. Percentages may not add up to 100 as a result of missing data or rounding.
b
Indicates prob > Rao-Scott v2 test statistic.
c
Indicates 0.0125 > prob(Rao-Scott v2 test statistic). We calculated a(0.0125) according to Bonferroni, such that familywise error is 0.05. We calculated test statistics for non-Hispanic Whites versus African Americans; non-Hispanic Whites
versus Hispanics; African Americans versus Hispanics; non-Hispanic Whites versus others.
d
Indicates that depression rates are statistically significantly different between subgroups, P < .05.
e
Indicates that treatment rates among those diagnosed with depression are statistically significantly different between subgroups, P < .05.

American Journal of Public Health | February 2012, Vol 102, No. 2


calculations (except sample sizes) to reect
national estimates.
RESULTS
Table 1 presents the population characteris-
tics of the 4 racial/ethnic groups. The most
pronounced difference was in their income:
approximately one quarter of non-Hispanic
Whites reported low incomes, whereas a major-
ity of the African Americans and others were
poor, and 78% of the Hispanics were poor.
Hispanics had the lowest education levels, fol-
lowed by African Americans. Many African
Americans and the majority of Hispanics and
others, but only 8% of non-Hispanic Whites,
were dually enrolled in Medicaid. There were no
substantial differences by gender or perceived
access to care. Non-Hispanic Whites and others
had fewer ADL and IADL impairments than did
African Americans and Hispanics and were less
likely to rate their health as fair or poor.
Hispanics reported the highest levels of depres-
sion symptoms, but the difference was not sub-
stantial, although it was statistically signicant.
The overall depression diagnosis rate was
6.2%. Rates varied signicantly (P < .05) by
race/ethnicity (6.4% for non-Hispanic Whites,
4.2% for African Americans, 7.2% for His-
panics, and 3.8% for others; Table 1). De-
pression diagnosis rates also varied by gender,
income, health insurance, prescription drug
coverage, perceived access to care, heath status,
and symptom level (Table 1). Treatment rates
were associated with education, income, pre-
scription drug coverage, residence (urban vs
rural), and depression diagnosis (major de-
pressive disorder vs other). These variables
also varied signicantly by race/ethnicity and
could have mediated the association between
depression care indicators and race/ethnicity
(Table 1). Thus, we estimated a series of nested
logistic regression models to examine whether
controlling for these factors (Tables 2 and 3)
explain some of the association between race/
ethnicity and the outcome variables. We suc-
cessively added controls for membership in
other traditionally underserved groups (model
1); socioeconomic characteristics (education
and income, in model 2); insurance and per-
ceived access to services (model 3); clinical
indicators (model 4), and depression symptoms
(model 5).
February 2012, Vol 102, No. 2 | American Journal of Public Health
RESEARCH AND PRACTICE
When we adjusted for inclusion in other
medically underserved subgroups on the basis
of gender, age, and geographic location, the
racial/ethnic differences in diagnosis rates
persisted. The odds of receiving a depression
diagnosis were lower for African Americans
than for non-Hispanic Whites (model 1; ad-
justed odds ratio [AOR] = 0.60; 95% con-
dence interval [CI] = 0.46, 0.78). This pattern
remained after controlling for income and
education (model 2), insurance coverage and
perceived access to care (model 3), and general
health measures (model 4; AOR = 0.50; 95%
CI = 0.38, 0.65). The ndings were also robust,
controlling for depression symptoms (model 5;
AOR = 0.53; 95% CI = 0.41, 0.69). In fact,
including symptoms had little effect on the
odds ratio for African Americans, suggesting
that little of the bivariate difference could be
explained by differences in self-reported de-
pression symptoms. Comparing model 1 with
model 5, it is also of interest that the racial/
ethnic disparity was undiminished after
adjusting for the full set of covariates. We
observed a similar pattern for non-Hispanic
others but not for Hispanics. In all 5 models,
the odds of receiving a depression diagnosis
were not statistically different for Hispanics
than for non-Hispanic Whites.
We operationalized the second outcome,
treatment of elderly with a depression diagno-
sis, as receipt of either psychotherapy or anti-
depressants. As we observed for diagnosis
rates, treatment rates and modalities differed
by race/ethnicity: 27.0% of non-Hispanic
Whites versus 39.6% of African Americans did
not receive any treatment (P < .05; Table 1).
Treatment modalities were different across
racial/ethnic subgroups as well (P < .001; data
not shown). Among non-Hispanic Whites,
57.9% were treated with antidepressants
alone, 4.3% with psychotherapy only, and
10.8% with both antidepressants and psycho-
therapy. Antidepressant use rates were lower
among African Americans (52.5%) than
among Whites (68.7%); whereas 58.0% of
Hispanics used antidepressants. Rates of psy-
chotherapy use among African Americans
(18.0%) and Whites (15.0%) were not sub-
stantially different.
Racial/ethnic differences in depression
treatment were robust, regardless of the control
variables included in the model (Table 3).
Akincigil et al. | Peer Reviewed | Research and Practice | 323
African Americans were approximately half as
likely to receive treatment as were non-His-
panic Whites, controlling for sociodemographic
characteristics, perceived access to care, and
global health (model 4; AOR = 0.42; 95% CI =
0.35, 0.49). Differences in symptoms and
disease severity did not explain the gap we
found (model 5; AOR = 0.53; 95% CI = 0.41,
0.69). Treatment difference could not be
explained by fewer symptoms among African
Americans. We also observed similar patterns
for Hispanics and non-Hispanic others.
DISCUSSION
During the years 2001 through 2005, mi-
norities were less likely to receive a depression
diagnosis and be treated for it than were non-
Hispanic Whites. These differences remained
after adjusting for depression symptoms and
severity, suggesting that there may be dispar-
ities, as dened by the Institute of Medicine.29
Our ndings are consistent with the thesis that
there is continuing underrecognition and under-
treatment of depression among minority elders,
net of differences in underlying symptoms, which
persisted into the rst decade of the 21st century
despite overall increases in diagnosis and treat-
ment rates.30,31
Differences in depression diagnosis rates
among racial/ethnic groups may be the result
of both differences in underlying rates of
pathology and underdiagnosing of depression
in certain groups. Data on the underlying rates
of pathology among adult populations are in-
consistent. Some community-based epidemio-
logical studies on adults report that African
Americans have lower rates of depression than
do non-Hispanic Whites32---35; whereas the Ep-
idemiologic Catchment Area Study found that
the prevalence of depression is similar across
racial/ethnic groups.36,37 Although the MCBS
does not include a full-scale depression measure
(such as the Patient Health Questionnaire-9),
adjustment for self-reports of depressed mood
and anhedonia in the 2-item screener did not
affect the racial/ethnic differences in diagnosis
rates, suggesting that differences in symptoms (as
identied by self-report) do not explain the gap
and that there is a need to look at other factors,
which may include racial/ethnic differences in
depression help-seeking patterns,38 differences in
access to health care that are not captured by our
 RESEARCH AND PRACTICE

TABLE 2Patterns of Depression Diagnosis: Medicare Current Beneficiary Survey, United States, 20012005

Population Characteristics Model 1,a AOR (95% CI) Model 2,b AOR (95% CI) Model 3,c AOR (95% CI) Model 4,c AOR (95% CI) Model 5,c AOR (95% CI)

Race/Ethnicity
Non-Hispanic White (Ref) 1.00 1.00 1.00 1.00 1.00
African American 0.60 (0.46, 0.78) 0.52 (0.30, 0.90) 0.52 (0.40, 0.68) 0.50 (0.38, 0.65) 0.53 (0.41, 0.69)
Hispanic 1.02 (0.68, 1.53) 0.82 (0.43, 1.54) 0.80 (0.52, 1.21) 0.79 (0.52, 1.21) 0.79 (0.52, 1.19)
Non-Hispanic other 0.59 (0.40, 0.88) 0.66 (0.29, 1.50) 0.44 (0.29, 0.65) 0.46 (0.31, 0.68) 0.49 (0.33, 0.72)
Supplemental health insurance
Medicaid (Ref) ... ... 1.00 1.00 1.00
Other supplemental insurance ... ... 0.71 (0.59, 0.84) 0.88 (0.74, 1.04) 0.92 (0.77, 1.10)
None (Medicare only) ... ... 0.21 (0.17, 0.28) 0.26 (0.20, 0.34) 0.27 (0.21, 0.35)
Prescription coverage
Comprehensive coverage (Ref) ... ... 1.00 1.00 1.00
Limited coverage ... ... 0.73 (0.66, 0.81) 0.76 (0.69, 0.84) 0.76 (0.68, 0.84)
No coverage ... ... 0.76 (0.64, 0.90) 0.82 (0.69, 0.97) 0.82 (0.69, 0.97)
Perceived access to care
Cost barrier
No (Ref) ... ... 1.00 1.00 1.00
Yes ... ... 1.45 (1.20, 1.74) 1.23 (1.02, 1.49) 1.09 (0.89, 1.33)
Service availability barrier
No (Ref) ... ... 1.00 1.00 1.00
Yes ... ... 1.12 (0.97, 1.29) 1.00 (0.86, 1.15) 0.97 (0.84, 1.12)
Dissatisfaction with care
No (Ref) ... ... 1.00 1.00 1.00
Yes ... ... 1.43 (1.27, 1.61) 1.26 (1.12, 1.42) 1.16 (1.02, 1.31)
Clinical indicators
Self-reported health status
Fair or poor (Ref) ... ... ... 1.00 1.00
Excellent, very good, or good ... ... ... 0.53 (0.47, 0.59) 0.60 (0.53, 0.67)
ADL impairment ... ... ... 1.22 (1.15, 1.31) 1.12 (1.05, 1.20)
IADL impairment ... ... ... 1.19 (1.11, 1.27) 1.13 (1.06, 1.21)
Depression symptoms
Low (Ref) ... ... ... ... 1.00
Medium ... ... ... ... 3.05 (2.64, 3.52)
High ... ... ... ... 4.04 (3.39, 4.80)

Note. ADL = activities of daily living; AOR = adjusted odds ratio; CI = confidence interval; IADL = instrumental activities of daily living. AORs are from logistic regression models in which the dependent
variable is the binary indicator of depression diagnosis during the year of observation.
a
Controlling for demographic characteristics.
b
Controlling for demographic characteristics and socioeconomic status.
c
Controlling for demographic characteristics, socioeconomic status, coverage, and access variables.

explanatory variables, or differences in providers
clinical detection of depression.39
Evidence suggests that help-seeking patterns
differ by race/ethnicity, contributing to the gap
in depression diagnosis rates. Stigma, patient
attitudes, and knowledge also may vary by
race/ethnicity.40,41 A recent vignette study
found that African Americans were more likely
than were their non-Hispanic White counter-
parts to believe that mental health problems
would improve on their own.42 Low-income
African Americans who were engaged in psy-
chotherapy reported that stigma, dysfunctional
coping behavior, shame, and denial could be
reasons some African Americans do not seek
professional help.43 African Americans and His-
panics are more likely than are Whites to seek
depression care from nonmedical providers, such
as pastors or lay counselors.44---46
Racial/ethnic disparities in depression diag-
nosis rates may also result from racial/ethnic
differences in the patient---physician relationship
during the clinical encounter. African Americans
report greater distrust of physicians and poorer
patient---physician communication than do
White patients.47,48 Communication difculties
may contribute to lower rates of clinical detection
of depression among depressed African Ameri-
cans because the diagnosis of depression de-
pends to a considerable degree on communica-
tion of subjective distress. Such communication
difculties are more common among African
American than among non-Hispanic White

324 | Research and Practice | Peer Reviewed | Akincigil et al. American Journal of Public Health | February 2012, Vol 102, No. 2
 RESEARCH AND PRACTICE

TABLE 3Patterns of Depression Treatment Among Enrollees Diagnosed With Depression: Medicare Current Beneficiary Survey,
United States, 20012005

Population Characteristics Model 1,a AOR (95% CI) Model 2b AOR (95% CI) Model 3c AOR (95% CI) Model 4c AOR (95% CI) Model 5c AOR (95% CI)

Race/Ethnicity
Non-Hispanic White (Ref) 1.00 1.00 1.00 1.00 1.00
African American 0.51 (0.33, 0.78) 0.50 (0.42, 0.58) 0.45 (0.38, 0.53) 0.42 (0.35, 0.49) 0.45 (0.30, 0.66)
Hispanic 0.59 (0.29, 1.21) 0.69 (0.52, 0.92) 0.58 (0.43, 0.79) 0.57 (0.42, 0.77) 0.61 (0.30, 1.25)
Non-Hispanic other 0.23 (0.10, 0.52) 0.43 (0.32, 0.58) 0.34 (0.25, 0.46) 0.35 (0.25, 0.47) 0.16 (0.07, 0.39)
Supplemental health insurance
Medicaid (Ref) ... ... 1.00 1.00 1.00
Other supplemental insurance ... ... 0.75 (0.66, 0.86) 0.96 (0.84, 1.1) 0.85 (0.60, 1.19)
None (Medicare only) ... ... 0.63 (0.56, 0.72) 0.8 (0.70, 0.92) 0.71 (0.43, 1.17)
Prescription coverage
Comprehensive coverage (Ref) ... ... 1.00 1.00 1.00
Limited coverage ... ... 0.69 (0.64, 0.74) 0.71 (0.66, 0.77) 0.57 (0.46, 0.72)
No coverage ... ... 0.48 (0.43, 0.55) 0.52 (0.46, 0.58) 0.55 (0.41, 0.73)
Perceived access to care
Cost barrier
No (Ref) ... ... 1.00 1.00 1.00
Yes ... ... 1.44 (1.26, 1.64) 1.19 (1.04, 1.35) 0.87 (0.60, 1.28)
Service availability barrier
No (Ref) ... ... 1.00 1.00 1.00
Yes ... ... 1.23 (1.13, 1.35) 1.07 (0.98, 1.18) 1.04 (0.82, 1.33)
Dissatisfaction with care
No (Ref) ... ... 1.00 1.00 1.00
Yes ... ... 1.33 (1.22, 1.45) 1.16 (1.06, 1.27) 0.94 (0.73, 1.20)
Clinical indicators
Self-reported health status
Fair or poor (Ref) ... ... ... 1.00 1.00
Excellent, very good, or good ... ... ... 0.57 (0.53, 0.62) 1.14 (0.92, 1.41)
ADL impairment ... ... ... 1.35 (1.29, 1.42) 1.09 (0.96, 1.24)
IADL impairment ... ... ... 1.28 (1.21, 1.34) 1.09 (0.95, 1.25)
Diagnosis
Major depressive episode ... ... ... ... 1.00
Other ... ... ... 0.39 (0.29, 0.52)
Depression symptoms
Low (Ref) ... ... ... ... 1.00
Medium ... ... ... ... 1.10 (0.83, 1.46)
High ... ... ... ... 1.16 (0.79, 1.69)

Note. ADL = activities of daily living; AOR = adjusted odds ratio; CI = confidence interval; IADL = instrumental activities of daily living. AORs are from logistic regression models in which the dependent
variable is the binary indicator of depression treatment utilization (either antidepressant fill or psychotherapy utilization) during the year of observation. As a result of cell size considerations, we
limited analyses to the subsample of non-Hispanic Whites and African Americans.
a
Controlling for demographic characteristics.
b
Controlling for demographic characteristics and socioeconomic status.
c
Controlling for demographic characteristics, socioeconomic status, coverage, and access variables.

patients.49,50 Race/ethnicity concordant visits,
which are presumed to be less common for non-
Whites, also have been characterized by better
communication.51
Racial/ethnic differences in the clinical pre-
sentation of depression may further explain the
lower rates of depression detection among
African American patients. Studies of adult
populations suggest that symptom presentation
for mental health disorders varies by race/
ethnicity.52 Symptom presentation by African
Americans may differ from what most clinicians
are trained to expect on the basis of clinical
stereotypes, resulting in clinical misdiag-
noses.14,30 African Americans may be more
likely to present with predominantly somatic and
neurovegetative depression symptoms and less
prominent mood or cognitive symptoms, which

February 2012, Vol 102, No. 2 | American Journal of Public Health Akincigil et al. | Peer Reviewed | Research and Practice | 325

may complicate detection and diagnosis.14 In
a randomized clinical trial of depression treat-
ment in primary care, depressed African Amer-
icans were more likely to have symptoms of poor
physical health, pain, and somatization than were
their non-Hispanic White counterparts.53
Finally, monetary factors may also play
a role. Among Medicare beneciaries, African
Americans are substantially less likely than
are non-Hispanic Whites to have private sup-
plemental insurance that covers charges
larger than standard Medicare-approved
amounts.54,55 Differences in provider reim-
bursement may favor increased clinical detection
of depression in White patient groups if higher
payment rates result in longer visits. Our data
were collected before the implementation of the
Medicare Part D drug benet. As expected, both
diagnosis and treatment rates were higher for
those who had comprehensive prescription drug
coverage than for enrollees with limited or no
coverage. Yet prescription drug coverage was not
mediating the racial/ethnic gap, suggesting that
disparities may have persisted following Medi-
care Part D implementation.
Various factors may contribute to racial/
ethnic differences in the treatment of those
diagnosed with depression. Access barriers to
their preferred mode of treatment may con-
tribute to lower rates of treatment among
African Americans. Some evidence suggests
that African Americans and Latinos are less
likely to accept antidepressant treatment than
are non-Hispanic Whites.56---59 Consequently,
we operationalized treatment as the receipt of
psychotherapy or antidepressants (the Institute of
Medicine denes a disparity as differences in the
medical treatment provided to members of
different racial/ethnic groups that were not
justied by the underlying health conditions or
treatment preferences). We found that the use of
psychotherapy was limited among both non-
Hispanic Whites and African Americans. It was
not possible to determine whether low rates of
psychotherapy stemmed from patient prefer-
ences or from access barriers that could differ-
entially affect non-Whites, such as high out-of-
pocket costs60 or a limited supply of mental
health providers serving their community.61
Geographic-level differences in the supply of
mental health services, particularly psychosocial
services, may be a signicant source of treatment
differences: there may be inadequate access to
326 | Research and Practice | Peer Reviewed | Akincigil et al.
RESEARCH AND PRACTICE
mental health care in poor communities, where
non-Whites are more likely to live.62
Most interventions to reduce racial/ethnic
differences in depression care attempt to do so
by enhancing access to care, screening, or
improving processes of care through process
improvement strategies.63 Studies have found
that multicomponent chronic disease manage-
ment interventions have improved depression
outcomes for non-White populations, with case
management as a critical component.63 For
example, in the IMPACT study, we observed
improved outcomes and eliminated disparities
among older adults with depression through an
intervention that provided case management,
patient education, and psychotherapy; non-
Whites enrolled in this intervention had out-
comes similar to those of non-Hispanic Whites.64
Quality improvement programs for depressed
primary care patients have also improved health
outcomes and the unmet need for appropriate
care among Latinos and African Americans
relative to Whites.65 Public policy options to
combat these disparities include public nancial
incentives for primary care doctors and psychi-
atrists to practice in poor communities and
incentives to increase the proportion of disad-
vantaged racial/ethnic groups in the health care
workforce. Incorporating cross-cultural educa-
tion into health professional training may also
reduce these differences in diagnosis and treat-
ment.66
Limitations
First, some of the patients classied as un-
treated may have received counseling for their
depression from non-Medicaid or non-Medi-
care providers (e.g., pastors or lay counselors).
Second, the cell sizes for Hispanics and others
were relatively small, which could make the
estimates imprecise and underpowered. The
survey items measuring depression symptoms
and the response formats were similar to those
in the validated PHQ-2 but were not exactly the
same. Most importantly, the MCBS items refer
to the past year, whereas the PHQ-2 refers to
the past 2 weeks. Fourth, our ndings are
founded on fee-for-service enrollees. Managed
care enrollees are slightly younger, reported
better health status, have fewer limitations, and
are more likely to live in urban areas.67 Fifth,
the MCBS does not capture stigma and other
cultural factors that may mediate racial/ethnic
American Journal of Public Health | February 2012, Vol 102, No. 2
differences in depression care. Finally, we used
broad denitions of depression treatment, and
for many patients, use of any psychotherapy or
antidepressant treatment is not necessarily ade-
quate depression treatment.68
Conclusions
Our results document the substantial race/
ethnicity-related differences that have persisted
for depression care of community-dwelling el-
derly Medicare beneciaries. Efforts are needed
to reduce the burden of undetected and un-
treated depression and to identify the barriers
that generate disparities in detection and treat-
ment. Promising approaches include providing
universal depression screening and ensuring
access to care in low-income and minority
neighborhoods. An increase in the reimburse-
ment of case management services for the
treatment of depression may also be effective.
Continued surveillance and research docu-
menting racial/ethnic differences in depression
diagnosis and treatment among the elderly is
also necessary to evaluate whether progress in
eliminating any disparities continues. j
About the Authors
Ayse Akincigil, Karen A. Zurlo, and Stephen Crystal are
with the School of Social Work, Rutgers, The State
University of New Jersey, New Brunswick, NJ. Mark Olfson
is with the Department of Psychiatry, Columbia University,
New York, NY. Michele Siegel and James T. Walkup are
with the Center for Health Services Research on Pharma-
cotherapy, Chronic Disease Management, and Outcomes,
Rutgers.
Correspondence should be sent to Ayse Akincigil, 112
Paterson St., New Brunswick, NJ 08901 (e-mail: aakinci@
rci.rutgers.edu). Reprints can be ordered at http://www.
ajph.org by clicking the Reprints/Eprints link.
This article was accepted June 20, 2011.
Contributors
A. Akincigil, M. Olfson, J. T. Walkup, and S. Crystal
contributed to the study concept and design. A. Akincigil
performed the data analysis. A. Akincigil, M. Olfson,
and S. Crystal contributed to data interpretation. All
authors contributed to article preparation.
Acknowledgments
This study was supported by the National Institute of
Mental Health (NIMH; award R01 MH60831) and by
the Agency for Healthcare Research and Quality (AHRQ)
through a cooperative agreement for the Center for
Research and Education on Mental Health Therapeutics
at Rutgers (award U18HS016097) as part of AHRQs
Centers for Education and Research on Therapeutics
Program.
An earlier version of this article was presented at the
Annual Meeting of the Gerontological Society of America.

Note. The content is solely the responsibility of the
authors and does not necessarily reect the ofcial views
of NIMH or AHRQ.
Human Participation Protection
Rutgers institutional review board approved this study.
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