Our results suggest that among racial and ethnic minorities, African Americans are particularly unlikely to be retained in care for depression as compared to Non-Latino Whites. Despite our adjusting for several factors known to influence retention for ethnic minorities, African Americans continue to demonstrate lower retention in depression treatment. This is despite over seventy-percent of the African American sample accessing specialty mental health services, which overall was associated with treatment retention.
Previous studies have examined reasons for low mental health services use among minority populations and have considered the influence of experienced mistreatment and social exclusion from health care among African Americans (41
). Ward (14
) found that African- American clients in counseling engage in an ongoing assessment process beginning in the first session. If the assessment is negative, Ward (14
) also found that African American clients are more likely to engage in superficial disclosing and to terminate counseling quickly. Anglin et al. (43
) found that while African Americans were more likely than non-Latino Whites to believe that mental health professionals could help individuals with major depression, they were also more likely to believe mental health problems would improve on their own. Additional explanations could be the lack of racial concordance between patient and provider in the clinical encounter which might be a more salient issue for Blacks who prefer to be seen by a provider of their same race (11
). Given the low percentage of Black psychiatrists (3%) and psychologists (2%) in the US (44
), racial concordance seems like an unlikely event that may increase the opportunities for drop out.
Surprisingly, we find that Asians and Latinos are not significantly less likely to be retained in care as compared to their non-Latino White counterparts. In this regard, the ethnic racial differences in treatment retention in this paper vary from what has been previously reported in other studies regarding lower rates of retention in treatment for Latinos and other ethnic racial minorities (10
). Few studies have compared treatment adherence or retention across race and ethnicity. A review of the literature conducted by Lanouette et al. (47
) examining racial variations in adherence to psychotropic medications demonstrated that many studies have found lower adherence by both Latino and African American patients as compared to non-Latino Whites. Their findings were based mostly on regional studies with only three nationally representative studies available for inclusion in the review. However, risk factors for non-adherence noted in that review included being monolingual Spanish speaking, lacking health insurance, experiencing access barriers to high-quality care, and having lower socio-economic status. We adjusted for many of these same potential barriers in evaluating treatment retention in our study sample. Close to sixty-percent of the Latino and Asian sample were English proficient. In addition, 70% of Latinos and 75% of Asians in our sample had been seen in specialty mental health care. Le Meyer et al. (48
) found that for US born Asian Americans who are English proficient, use of primary care services is significantly associated with utilization of specialty mental health services, while immigrant and non English proficient patients in primary care do not tend to access or use specialty mental health services. The combination of English proficiency and access to specialty care may have assisted in treatment retention for Asians and Latinos in our study.
The sector of mental health care in which minorities are treated is one of the most important factors associated with retention in depression treatment. We found this to be the case even after adjusting for number of co-occurring psychiatric diagnoses, level of impairment and many factors known to be associated with poor treatment access and retention including poverty, education and insurance status. Even when we removed subthreshold depression, which may lend to potential diagnostic uncertainty and thus lead to variations in services use, we continue to find less retention for African Americans and by generalist care. The care available in specialized mental health services differs from what is usually available in primary care. The availability of collaborative services (i.e. combined therapy, psychopharmacology, and case management) within specialized mental health services may assist in retaining patients because of coordination of services and more intensive delivery of therapeutically effective treatment (31
). It also emphasizes that mental health care in primary care clinics may not be optimal. Research has found that individuals who seek mental health treatment in the primary care sector receive only two minutes on average of mental health treatment for depression during a primary care visit (50
). This may not be sufficient time to assess need for depression treatment (whether subthreshold or threshold depression) or to engage patients for ongoing treatment, especially ethnic minorities who already face multiple barriers and disparities in treatment. It is important to note that when we conducted our sensitivity analysis using three visits as a cutoff for retention, we no longer found ethnic-racial differences. This is a more relaxed criterion for retention which may be more attainable across race and perhaps even in primary care settings, but as discussed previously these fewer visits are not necessarily associated with any evidence of adequacy of care.
We are not able to establish causality based on the cross-sectional nature of the study and were only able to include individuals who were symptomatic according to the CIDI and had at least one treatment visit in the last 12 months. That is, we were not able to include individuals who may have been diagnosed with depression and completed treatment in a time period previous to the last 12 months. Small sample size may have limited power to detect differences for the Asian sample which demonstrated a trend towards less retention in care but did not reach significance. Although, we were able to examine satisfaction with treatment we were unable to further examine or address treatment expectations. Despite these limitations we were able to detect important variations by race and to identify the influence of type of treatment provider on retention in treatment in a nationally representative sample.