Access to care and those who fail to seek professional help are the primary barriers.
Nearly 8 percent of Americans are moderately or severely depressed, according to a Centers for Disease Control and Prevention (CDC) report. That amounts to about 25 million people. Yet not nearly enough are getting treatment.
Of those with severe symptoms — who made up 3 percent of the total — just over one-third said they had consulted a mental health professional in the previous year. Among those with moderate symptoms, only one in five had talked with a mental healthcare provider.
The reasons more Americans don’t seek treatment for depression are complex, says Carol Landau, PhD, a practicing psychologist and professor at Brown University. For many, access and awareness are the biggest barriers.
“It’s not just that people don’t seek treatment, but that they don’t feel they have access to treatment,” Landau says. “For some people, depression is the new normal. So you take a women who’s 35 and divorced, struggling at almost poverty level, and she’s sort of tired and has headaches and feels sort of hopeless and down. She’s going to just interpret that ultimately as the way her life is — rather than depression, which is treatable.”
Mental healthcare is an essential part of well-being. But insurance policies differ, and often consumers need to jump through several hoops to get approved for treatment — call a special 800 number for approval, for example, or have a particular diagnosis.
As a result, many end up seeking care from their primary care provider. Part of Landau’s role at Brown’s Alpert School of Medicine is to train doctors to better recognize and treat mental health conditions in the primary care setting. “Primary care doctors are on the front line of mental health, unbeknownst to them,” she says. “People don’t often get to the mental health professional, or they don’t feel they have coverage, or they can’t take the time. So it’s really important to continue to train primary care doctors to do some of this.”
Meanwhile, the CDC reports, those living below the poverty line are twice as likely to be depressed. In fact, poverty itself is a risk factor for depression, Landau says. “It’s just hard to get by, so if you don’t have enough money to support yourself and your kids, life is constantly difficult.”
In addition, the basics of mental health — healthy food, adequate sleep — can be harder to get in impoverished areas. Those in poverty are also exposed to violence, even trauma, more often than those in stable economic conditions. “Basically it’s sort of a straightforward direction from stress to increased stress hormones like cortisol to increased depression,” Landau says. “If you just think about your nervous system, constantly being sort of irritated, that can certainly lead to depression and other psychiatric problems.”
The highest rates of depression in the study were among women ages 40 to 59, 12.3 percent of whom reported moderate to severe symptoms. Adolescent and elder males reported the least symptoms, at 4 percent among males ages 12 to 17 and 3.4 percent for men over 60.
While women’s reported rates of depression dropped by nearly half after age 60 (to 7.1 percent), rates for depression among women are historically twice as high as men’s across the lifespan, a figure that holds across numerous studies.
It’s a pattern that has long concerned researchers, Landau notes. Women are more likely to be in poverty, to be responsible for child and elder care, and to experience violence, she says. For those who are part of a racial or ethnic minority, discrimination can add stress as well. “A lot of that can chip away at you and make you feel less empowered — and that, we know, makes people feel more depressed.”
Women may also value relationships more than men, and be more affected when relationships are rocky. “There’s evidence that women react more intensely to marital distress,” Landau says. “Even very high-achieving women in high-achieving positions value their family life a lot. … So you not only have work, family, home, but high expectations, and if you don’t meet those high expectations, you feel pretty bad about yourself.”
Meanwhile, men may be less likely to report being depressed, but they’re also more likely to be ashamed to seek help. “There’s still a stigma attached to any mental health issue, which is really too bad,” Landau says. “It’s more true for men than women, but that’s true for everybody.”
Since men may not share when something is wrong, depression symptoms among men can include substance abuse, recklessness, and violence. They also act more quickly: men are four times more likely to commit suicide than women. “Men may not be socialized to talk about their feelings,” Landau says, “but they pay the price in a different way.”
High out-of-pocket deductibles, common under the new Affordable Care Act, which took effect in 2014, may make people even less likely to seek treatment. “It’s a really tough situation,” Landau laments.
She suggests health plans should include 12 mental health sessions per year for preventive wellness.
“It’s shortsighted not to do that,” she argues. “If you have depression and you don’t have access to that treatment, you’re going to go to your primary care doctor with your low back pain and your headache and your lack of energy and get sent for lots of tests that are going to add up to far more than 12 sessions of psychotherapy.”
April 06, 2020
Christopher Nystuen, MD, MBA