This study has several important findings. First, older Mexican-origin men experience similar levels of past year clinical depression yet report much lower rates of depression diagnosis and treatment compared with older white men. Differences in self-reported depression treatment extend to both English and Spanish language preferring subgroups of Mexican-origin men. Second, the majority of the Mexican-origin and white older men who reported receiving depression treatment also met criteria for past year clinical depression, indicating that few achieved full remission. Together these findings highlight our need to improve diagnosis and treatment in primary care, particularly for those of Mexican-origin. Corresponding improvements in the quality of the depression care are also needed so that older men achieve full remission from depression.
The rate of depression treatment among Mexican-origin older men was surprisingly low considering ours is a primary care-based sample and is more in line with what has been found in community-based studies of Latinos. Prior community-based and mixed-sex epidemiological (Gonzalez et al., 2010
) and clinic studies (Lagomasino et al., 2005
) have found rates of depression care among whites to be 1.5 to 2 fold higher compared with Mexican-origins. In contrast, our study found a nearly three-fold gap between rates of primary-care based depression treatment in Mexican-origin and white older men. Our findings suggest that ethnic disparities in depression care may be amplified among men and additional studies are needed to replicate this finding in larger samples.
In our study, self-reported depression treatment was not significantly different for English and Spanish language preferring subgroups of Mexican-origin men. This finding differs from prior studies. Previous studies of elderly Latinos have found that Latinos with Spanish language preference, but not those who preferred to speak English, were at higher risk for depression under-treatment compared with whites (Gonzalez et al., 2001
, Gonzales et al., 2009
). One possible reason for this discrepancy is we studies only older men whereas prior studies were mixed-sex. Future studies examine the possibility that gender modifies the relationship between depression treatment and language in Mexican origin or other Latino populations.
Older Mexican-origin men were significantly less likely to report that a doctor had told them that they were depressed. This suggests that under-diagnosis or difficulties in the communication of diagnosis may also play an important role in under-treatment of depression in this primary care based sample. While a detailed discussion of the sources of under-diagnosis is beyond the scope of this paper, they may include physician factors (e.g. stereotypes, not asking about depression, failing to recognize men’s depression). For example, most physicians are trained to pay attention to the epidemiologic base-rates of disorders, which highlight depression among women, but not men. This may have the untoward effect of depression under-detection in men. Patient factors (e.g. stigma) may hinder men from expressing distress in ways that are not easily recognized by physicians. Additionally, lack of familiarity with the health system or experiences of discrimination, or lack of healthcare insurance may compound depression under-diagnosis and under – treatment for Mexican-origin men. If older Latinos are more averse to anti-depressant medication than whites (Cooper et al., 2003
), they may be less likely to seek help for depression in primary care settings.
The second major finding is that among those older men of both ethnic groups who reported receiving depression care, the majority remain highly symptomatic. While our study did not include a measure of treatment adequacy as some epidemiological studies have done (Gonzalez et al., 2010
), the fact that two-thirds of older men in primary care who reported receiving depression treatment continued to meet criteria for clinical depression suggests that inadequacy of treatment continues to be a major challenge (Young et al., 2001
). Our results are consistent with prior treatment trials showing that 70–80% of men receiving “usual care” do not achieve significant reduction in depressive symptoms and highlights the significant problems with quality of care after initial diagnosis and engagement in care (Unutzer et al., 2002
, Katon et al., 2010
, Mojtabai, 2001
). Research in primary care settings has shown that older men benefit as much from depression interventions as women and dissemination of effective collaborative care models to reach older men in primary care is clearly needed (Unutzer et al., 2002
The study findings should be interpreted in the context of this study’s strengths and limitations. In contrast to prior studies, we included older men who had been successfully treated for depression, allowing us to assess the full-spectrum of depression treatment. Another strength is that we assessed depression using face-to-face interviews and a measure of syndromal clinical depression (i.e. SCID) rather than relying on measures of depression symptoms. Several caveats should be considered when evaluating this study. First, while we used the SCID to assess current major depression, previous depression history and treatment were based solely on men’s self-report, which has the potential to introduce biases. Higher depression-related stigma among Mexican-origin men, for example, could have led to greater under-reporting of diagnosis or treatment compared with whites (Vega et al., 2010
). In addition, our sample was small by epidemiological standards, which may have limited our ability to detect any differences in receipt of psychotherapy. Another potential study limitation to generalizability was that our sample was drawn from a single geographic area. In addition, our measure of depression treatment did not permit us to examine adequacy of treatment. Because our measure of depression treatment was less stringent, far fewer older men were likely to be receiving treatment that we would consider to be guideline-congruent (Gonzalez et al., 2008
). Finally, our sample included only Mexican-origin men so caution should be used in generalizing to other Latinos, as prior work has demonstrated heterogeneity among Latino subgroups in terms of rates of depression and depression treatment (Gonzalez et al., 2010
, Jimenez et al., 2010
In conclusion, we found very low rates of depression treatment in older Mexican-Origin men, highlighting a gap in mental health services delivery in primary care for this population. Older Latinos who are not able to access treatment for their depression may experience more prolonged depressive episodes and associated suffering (Interian et al., 2011
). The high rates of depression under-treatment are taken on addition significance given that older Latinos are among the largest and fastest growing segments of seniors. (Angel and Hogan, 2004
). In addition, most older men, including white and Mexican-origin, who have received depression treatment in the past year remain clinically depressed. Thus an equally important challenge is ensuring that depression treatments are effective so that depression fully remits. Older adults incur important “costs” when being diagnosed and treated for depression, such as social (i.e. labeling) and resource-related (e.g. monetary costs of treatment) burdens. To offset these “costs” improved access must be linked to more adequate depression care, which will provide health benefits that outweigh these costs. In interventions based on the collaborative care model, older Latinos show improvements in depression-related outcomes that are comparable to or greater than whites (Bauer et al., 2011
, Arean and Ayalon, 2005
). Future efforts to reduce disparities in depression care for older men must address both access and quality-related challenges.