Antidepressant Use by Race

To the Editor: We read the recent article by Dan G. Blazer, M.D., Ph.D., et al. (1) with great interest. The article draws important attention to marked differences in antidepressant use by race in an elderly community sample and is a significant contribution to the literature in this area. We certainly agree with the authors that differences in antidepressant use between Caucasian and African American elders could have many causes.

These could include, as the authors noted, practitioners’ underdiagnosis of depression in elderly African Americans (in spite of the known similar prevalences of the disorder in these races when assessed in large-scale controlled studies). In fact, there is a growing literature suggesting that this phenomenon occurs in a variety of settings. In two separate studies of patients admitted to geropsychiatric acute inpatient units, Fabrega et al. (2) noted a lower proportion of elderly African Americans diagnosed with mood disorders and higher proportions of elderly African Americans diagnosed with psychotic disorders, and Mulsant et al. (3) found that elderly African American patients were significantly more likely to receive a diagnosis of schizophrenia. Leo et al. (4), in a study examining geropsychiatric consultation, found that African Americans were diagnosed with psychotic disorders and dementia significantly more often and with mood disorders significantly less often than Caucasians. In a large retrospective examination of a group of elderly patients treated within the Veterans Affairs health care system, we found that African Americans were significantly less likely to receive a diagnosis of depression than Caucasians (5); the rate of mood disorder diagnoses in elderly African Americans was less than half that of elderly Caucasians.

Differences in depression diagnoses between races in elderly samples could be due to patient factors (less reporting, different symptom presentation, or less use of formal health care settings for treating depression) or provider factors (misdiagnosis or clinician bias). On the basis of these findings, we agree that it is possible that the subjects in the study by Dr. Blazer et al. were much less likely to receive antidepressants because they were much less likely to be given the diagnosis of major depression in the clinical setting. The question remains as to whether elderly patients of different races receive different treatments once a diagnosis of depression is made. Further studies are needed to examine the contribution of both patient and provider factors to racial differences in this area.