Overall, depression does likely remit after two and a half years, but it is likely to recur. Our results showed that approximately 55% no longer met criteria for probable depression by 25 months. This indicates that many patients’ improve, approximating results reported in a previous non-Latino primary care sample, where approximately 45% no longer met major depression criteria at 24 months. (34
) In the current study, relapse/recurrence seems to be concerning, given that 37% of those whose depression improved/recovered experienced a relapse/recurrence of symptoms. This finding is consistent with the attention given to relapse/recurrence in the depression treatment research literature. (35
) In addition, it is concerning that only a minority of participants had improved/recovered at 6-months, leaving a considerable number to experience the burden and suffering of depression for substantial period of time. Thus, our data show that efforts should target earlier improvement/remission among Latino primary care patients, as well as reduce rates of relapse/recurrence. Our overall findings pertaining to relapse/recurrence, in combination with high rates of underutilization of treatment, are consistent with recent findings showing that minority groups are more likely to experience recurrent types of major depression compared to non-Latino whites. (37
Our study suggests that improving key mental health disparity determinants hold promise for achieving earlier treatment benefit and maintenance of gains, as our predictors were shown to influence the course of depressive symptoms. Of note was the important role of stigma as a barrier to depressive symptom remission among Latino primary care patients with depression. Specifically, the results of this study showed that the presence of stigma was associated with an increased likelihood of depressive symptom persistence. This effect was observed to be independent of antidepressant use. Such a finding adds to the accruing literature documenting the treatment complicating effect of stigma on mental health outcomes. (38
) Stigma is a frequently discussed barrier to mental healthcare among Latinos and the current study bolsters the significance of this issue by documenting the deleterious effect of stigma on long-term depression outcomes among Latinos in primary care.
The results of the study also showed low rates of antidepressant utilization. Our rates of self-reported antidepressant utilization, ranging from 28 – 33%, are consistent with rates of antidepressant utilization previously reported among Latinos with depression in primary care. (11
) Moreover, our findings directly link antidepressant utilization with long-term outcomes, showing that non-utilization worsened the trajectory of depressive symptoms. It also seems likely that these low rates of antidepressant utilization contributed to the low number of participants achieving depression symptom improvement/remission by six-months. While a consideration is whether participants accessed other treatments in specialty care settings, our data indicate that very small numbers attended specialty care (i.e., between 3–5 participants at each timepoint). Thus, the study’s results confirm that improving the utilization of antidepressants in primary care among Latinos remains a priority.
We further hypothesized that doctor-patient communication that was perceived to be favorable would enhance depression outcomes, a finding that was partially supported by the growth modeling. This finding adds to the accumulating literature that links important health outcomes to doctor-patient communication. (21
) The current results support the examination of communication ingredients that may be particularly effective for Spanish-speaking Latinos. These findings also support the use of interventions targeting the communication of Latino patients (41
) or physicians, (42
) particularly those that are patient-centered.
The results of the current study provide support for a number of clinical services and practice strategies. Strategies to increase engagement with antidepressant treatment will likely yield improved outcomes. Currently, there are a number of interventions available that hold promise improving engagement among Latinos. (41
) These interventions also have the potential to address depression stigma by either increasing patient treatment empowerment or by helping patients view antidepressant treatment in ways that are more consonant with models of coping within their community (e.g., struggling against problems instead of taking medications). Engagement strategies can also include awareness efforts that utilize culturally-focused educational approaches such as fotonovelas
) Finally, while doctor-patient communication can be improved by adopting key components of patient-centered communication (e.g., eliciting patient treatment preference, collaborative treatment planning), it should also include communicating an understanding of the stigma issues associated with antidepressant use among Latinos. (14
) Such communication can also help patients find ways in which antidepressant treatment can be viewed compatibly with their own models of coping with depression. (43
The current study has a number of limitations. First, our results linking depression trajectory and stigma are correlative and cannot differentiate between a number of interpretations. For example, it may be that worsened course of symptoms leads to greater stigma, as self-esteem and social functioning may be negatively affected by the persistence of depressive symptoms. Another interpretation is that the perception of stigma towards depression complicated remission. Accordingly, baseline stigma has been shown to prospectively predict self-esteem at six and 24 months follow-up. (38
) Consistent with this interpretation, our findings showed that the harmful effects of antidepressant stigma can be seen as early as six months. While another interpretation to consider is that stigma negatively influences depression remission via reduced treatment engagement, our findings show that stigma’s effect on depression is independent of antidepressant utilization. An addition interpretation would be that depression severity and stigma interrelate in multiple ways, having reciprocal effects, including an interplay with treatment engagement. While we cannot differentiate between these interpretations, our results highlight the importance of stigma in the long-term course of depressive illness among Latinos in primary care.
Second, although the PHQ-9 has good agreement with a clinician interview for major depression, (29
) it is not a structured psychiatric research interview for assessing major depression. Therefore, care should be taken when comparing rates of depression recurrence with those of previous primary care studies, (34
) as these studies employed a structured diagnostic interview. The current results should therefore be interpreted as a preliminary estimate of the course of depression among Latinos in primary care.
Third, a measure of stigma was included in our research protocol during the later timepoints of the study, which provided an incomplete picture of how stigma affects care at all data points. While our results establish the key influence of antidepressant stigma during late follow-up periods, they do not help us understand the role of stigma when patients initiate treatment.
Fourth, some caution is warranted in interpreting the results given that the majority of this Latino sample had access to health insurance. This may raise some questions pertaining to generalizability given that low rates of health insurance funding are observed among Latinos. (45
) Despite this limitation, however, this study adds to existing evidence showing that disparities in care continue to be observed, even among Latinos who have access to health insurance. (11
In conclusion, our results illustrate the long-term course of depressive symptoms among Latinos in primary care and that it is characterized by slow improvement and relapse/recurrence in a significant proportion of cases. Issues frequently discussed as relevant to Latino depression care disparities play a key role in the long-term course of depressive illness in primary care.