Racial disparities in diagnosis and treatment of major depression
People worldwide are suffering with mental health challenges now more than ever. Social distancing and remote work and school have translated into emotional distancing for many. The pandemic has magnified the challenges at home and abroad, and some racial and ethnic groups suffer disproportionately.1,2 Quantifying the extent of racial and ethnic inequities in mental health can help us better understand how to address them.
This study investigates disparities in the prevalence of diagnosis and treatment of major depressive disorder, or major depression3, between majority White, Black and Hispanic communities. Our analysis spans 2016 to 2020 and is based on the medical claims of 3.1 million Blue Cross and Blue Shield (BCBS) commercially insured individuals with major depression between the ages of 12 and 64. For additional insights, we surveyed more than 2,700 adults, aged 18 to 75, about their attitudes and perspectives around mental health and how they access care.
This is the second in a series of reports supporting the Blue Cross and Blue Shield national strategy to address racial disparities in health. The first report in our series examined maternal health; future reports will explore disparities in diabetes and heart health.
1. Major depression goes undiagnosed and untreated at disproportionally greater rates in majority Black and Hispanic communities, leading to unnecessary suffering.
2. The presence of more mental and behavioral health providers in Black and Hispanic communities is associated with higher diagnosis rates for major depression. This suggests that increased access to these providers could mitigate the underdiagnosis of major depression in these communities.
3. Rates of treatment for major depression are lowest in Hispanic communities and lower in Black communities than in White communities. When treated for major depression, Black and Hispanic communities have a lower frequency of both prescription drug treatment and counseling.
TRENDS AND DISPARITIES IN THE DIAGNOSIS OF MAJOR DEPRESSION
Major Depression Diagnosis Rate Overall: The rate of diagnosed major depression increased steadily from 2016 to 2019 and then leveled off in 2020 (see Exhibit 1).
Exhibit 1: Prevalence of Diagnosed Major Depression 2016 - 2020
DISPARITIES IN DIAGNOSIS OF MAJOR DEPRESSION BY COMMUNITY RACE OR ETHNICITY
The prevalence of diagnosed major depression is 31% lower for majority Black communities and 39% lower for majority Hispanic communities than for White communities (see Exhibit 2). Many factors suggest that major depression may be significantly underdiagnosed among Black and Hispanic communities including:
- Rates of depression are likely the same: The Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey4 found that Black and Hispanic respondents had equal or higher rates of depression than Whites. Similarly, the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health5 found that more Black and Hispanic individuals reported a moderate to severe impact from depression on their lives, including their ability to manage at home, work and close relationships compared to White respondents.
- Stigma may influence the decision to seek care: Responses to a recent Blue Cross Blue Shield Association survey6 of 2,700 adults suggest greater social stigma around mental health issues in Black and Hispanic communities may influence a person’s likelihood to seek care. Fifty-four percent of Black respondents and 47% of Hispanic respondents reported that individuals with mental health conditions in their communities “are looked down upon.” That was the perception of only 38% of White respondents. Such perceived stigma, combined with the structural racism that may prevent historically marginalized communities from receiving equitable treatment, may compound the difficulty of asking for help.
Exhibit 2: Prevalence of Diagnosed Major Depression by Race/Ethnicity Communities in 2020
ACCESS TO CARE ASSOCIATED WITH DISPARITIES IN DIAGNOSIS
Increased access to mental health care providers in Black and Hispanic communities is associated with major depression diagnosis rates more similar to those of White communities. Specifically, increased access to mental health care providers7 is associated with a three-fold higher relative increase of major depression diagnoses for Black communities and a four-fold higher increase for Hispanic communities than for White communities (see Exhibit 3)
Exhibit 3: Prevalence of Diagnosed Major Depression by Behavioral Healthcare Provider Access7 and Race, 2020
RACIAL AND ETHNIC DISPARITIES IN THE TREATMENT OF MAJOR DEPRESSION
DISPARITIES IN RATES OF TREATMENT
Overall, the rate of prescription drug treatment for those diagnosed with major depression has declined from 64% in 2018 to 59% in 2020, whereas counseling rates have remained steady. There are prescription drug and counseling utilization differences when segmented by race and ethnicity:
- Overall treatment of major depression in Hispanic communities declined 13% from 2018 to 2020 compared to a 7% and 8% decline for Black and White communities respectively.
- Rates of prescription treatment for diagnosed major depression are 13% lower for Black communities and 33% lower for Hispanic communities than for White communities (see Exhibit 4).
- Rates of counseling for diagnosed major depression are 21% lower for Hispanic communities than White communities, but there is no discernable difference between Black and White communities (see Exhibit 4).
Exhibit 4: Rate of Treatment for Diagnosed Major Depression by Type of Treatment and Race, 2020
DISPARITIES IN FREQUENCY OF TREATMENT
Not only did fewer members of Black and Hispanic communities receive prescription drug treatment for major depression (see Exhibit 4), but also the average frequency of prescription drug treatment was lower than in White communities (see Exhibit 5). Individuals from Black and Hispanic communities treated for major depression also received counseling less frequently than individuals in White communities (see Exhibit 5).
Exhibit 5: Frequency of Treatment for Major Depression by Treatment Type and Race, 2020
Survey: Exploring Public Attitudes Toward Diagnosis and Treatment6
To deepen our understanding of the disparities in the diagnosis and treatment of major depression in Black and Hispanic communities, the Blue Cross Blue Shield Association surveyed more than 2,700 adults, aged 18 to 75, about their attitudes around mental health. Creating a more diverse health care workforce and using culturally informed language could help improve levels of trust.
A CALL TO ACTION
Our findings on the disparities in diagnosis and treatment of major depression suggest significant under-diagnosis and unnecessary suffering. Gaining a better understanding of the extent and the drivers of these disparities is critical for achieving more equitable care. So, too, is an unwavering commitment to action.
Blue Cross and Blue Shield companies are committed to confronting and addressing inequities in mental health care while rigorously prioritizing the focus areas that will have the biggest impact:
- Address the youth mental health crisis
- Ensuring equitable access to mental health care
- Improving care integration of physical and mental health
- Confronting the unacceptable racial inequities in mental health
While a number of factors may play a role in the disparities in diagnosis and treatment of major depression, BCBS companies are committed to accelerating actions that improve mental health care. For example:
- We must ensure all patients have equitable access to the care they need, when they need it, no matter where they live or their racial, ethnic or linguistic background. BCBS companies are expanding telehealth services, identifying ways to connect patients with providers who match their preferences and advancing the use of non-clinical personnel such as peer support specialists to close the gaps.
- Integrating mental and physical health care is just as important. When care is fragmented, diagnoses are often missed and conditions go untreated. BCBS companies are empowering primary care physician practices to build care teams that can treat the whole person.
We recognize that collaboration is essential to transforming mental health. Change must be a collective effort. It will require business leaders, policymakers, researchers and community leaders to act with a sense of urgency. If we collaborate to solve the hardest problems, we can meaningfully improve outcomes for millions of Americans and reverse the mental health crisis we face today.
ABOUT MAJOR DEPRESSION
Major depression is a common and serious mental illness. It can cause feelings of sadness, loss of interest or pleasure in activities, changes in appetite or sleep patterns, a loss of energy, difficulty concentrating or making decisions and even thoughts of death or suicide. It can cause not just emotional but physical problems that affect a person’s ability to function. Major depression is also treatable with a variety of therapies, including medication and counseling. If you are experiencing symptoms of depression, talk to your doctor right away.8
If you or someone you love is experiencing a life-threatening emergency, call 911, or the National Suicide Prevention Lifeline at 800.273.8255.
This is the 36th study of the Blue Cross Blue Shield, The Health of America Report® series, a collaboration between Blue Cross Blue Shield Association and Blue Health Intelligence (BHI), which uses a market-leading claims database to uncover key trends and insights in health care affordability and access to care.
How we conducted this study:
The findings in this study are based on an analysis of Blue Cross Blue Shield Axis (BCBS Axis) data and other sources, described below. The BCBS Axis data contains claims of over 3.1 million commercially insured members with a major depression diagnosis for 2016-2020. Individuals must have had available medical and pharmacy benefits, and have been between the ages of 12 and 64 at the end of each calendar year. Treatment was identified for claims between the years 2018-2020.
Major depression was identified through use of the ICD-10 coding schema. Prevalence was estimated as a percentage of the population that had major depressive disorder (MDD) attached to at least one medical or pharmacy claim in each calendar year. Counseling/therapy was identified as services rendered by providers with appropriate counseling/therapy codes for diagnosed individuals. Prescription treatment was identified through claims with NPI codes consistent with identified anti-depressant class drugs.
Race/ethnicity of BCBS members is determined using residency ZIP codes. When more than 50% of the households in that ZIP code identify as Black, Hispanic or White the member is assigned to this racial/ethnic classification. This ZIP code data is from the 2019 American Community Survey (ACS). Mental health care provider access measures came from the Community Health Management Hub.
Survey findings in the report come from the BCBSA Mental Health Care Survey fielded in August/September 2021. It used a market-leading internet panel of consumers and results are based on responses from a sample of 2,700 insured adults with minimum quotas of 750 for Black and Hispanic respondents. Results were weight-adjusted by age, gender and education to ensure representativeness using the 2019 ACS.
- World Health Organization (2022). Mental Health and COVID-19: Early evidence of the pandemic’s impact: Scientific brief, 02 March 2022.
- National Center for Health Statistics, U.S. Census Bureau (2022). Household Pulse Survey, Indicators of Anxiety or Depression based on Reported Frequency of Symptoms.
- ICD-10 codes in the F32 and F33 groupings.
- “Prevalence of Depression Among Adults Aged 20 and Over: United States, 2013–2016”
- SAMHSA 2019 National Drug Use and Health Survey
- 2021 BCBSA Mental Health Care Survey.
- Eight mental health care providers per 10,000 residents is the median number of providers when aggregated at the ZIP code level.
- Definition adapted from the American Psychiatric Association, accessed on 10/5/2021.