Article

Health Disparities in Care for Depression Possibly

Obscured by the Clinical Significance Criterion

James C. Coyne, Ph.D. Background: In addition to symptoms,
DSM-IV criteria for major depression re-
quire clinical significance, operational-
Steven C. Marcus, Ph.D.
ized via reports of receipt of care or in-
terference in functioning. The authors
examined whether this confounding of
symptoms with receipt of care and/or
impairment affected racial differences
in rates of major depression in the com-
munity.
Method: Analysis of data from the 1999
National Health Interview Survey for a na-
tionally representative community sample
of 30,801 adults administered the depres-
sion module of the Composite Interna-
tional Diagnostic InterviewShort Form.
Results: There were no differences be-
tween African American subjects and
white/other subjects when diagnosis was
based solely on symptoms. Symptomatic
African American individuals were less
likely to endorse either receipt of care or
interference in functioning, so that the
clinical significance criterion served to re-
duce their rates of DSM-IV diagnosis.
Conclusions: The clinical significance
criterion underestimates of the rate of de-
pression for African American individuals
relative to white/other subjects, which
may in turn underestimate their need for
services.

(Am J Psychiatry 2006; 163:15771579)

T he DSM-IV clinical significance criterion for psychiat-

ric disorder requires either distress or disability. This crite-
rion has undergone a subtle but potentially crucial modifi-
cation in two key community mental health surveysthe
National Institute of Mental Health Epidemiologic Catch-
ment Area Program and the National Comorbidity Survey
that have served as the authoritative sources for estimates
of treatment need in the United States. For symptoms to
meet diagnostic criteria, the Diagnostic Interview Schedule
(used in the Epidemiologic Catchment Area study) and the
revised Composite International Diagnostic Interview
(used in the National Comorbidity Survey) each required
that endorsed symptoms be associated with either reports
of consulting a doctor or other professional or interference
in the respondents life or activities. This revised criterion
confounds diagnosis with receipt of care and impairment.
It might therefore yield underestimates of mental health
care need for populations facing significant barriers to ac-
cessing this care by failing to diagnose persons who did not
receive care or who had a different threshold at which they
felt they were impaired. We investigated this possibility by
comparing rates of major depression between African
American and white subjects using data from a large, na-
tionally representative community sample that included a
diagnostic inventory for depression.
Method
The National Health Interview Survey, conducted by the Na-
tional Center of Health Statistics and the Centers for Disease Pre-
vention and Control, is the major data collection instrument used
to assess the general health of the U.S. resident civilian noninsti-
tutionalized population. It is an annual health survey of a nation-
ally representative sample of households that in 1999 consisted of
30,801 adults interviewed in their homes by trained interviewers
from the U.S. Bureau of the Census. The 1999 survey instrument
included the depression module of the Composite International
Diagnostic InterviewShort Form that we scored using the
re co m m e nd ed alg o r i th m s ( h ttp :/ / w ww 3 .wh o.in t/ c i di /
CIDISFScoringMemo12-03-02.pdf ). Depression was present in
subjects 18 years of age or older who felt sad, blue, or depressed
for 2 weeks or more in a row in the past 12 months and whose feel-
ings had lasted half the day or longer everyday or almost every-
day, and who had three or more of six symptoms during the 2-
week period: lost interest in most things, more tired than usual,
unintentional weight changes, trouble falling asleep, trouble con-
centrating, felt worthless or no good, or thought a lot about death.
Subjects were asked How much did these problems interfere
with your life or activities: a lot, some, a little or not at all? Im-
pairment was present in those who responded a lot. Finally,
subjects received care if they indicated telling a doctor or other
professional (psychologist, social worker, counselor, nurse, clergy
or other helping professional) about the problems.
Rates of major depression were calculated by race and gender
defining major depression as: 1) symptoms only, 2) symptoms
and impairment, 3) symptoms and medical care, and 4) symp-
toms and either impairment or medical care. Chi-square statistics
tested for differences in rates. Risk ratios and their 95% confi-
dence intervals (CI) are used to present effect sizes. All statistical
analyses were conducted using SUDAAN (version 9) (Research
Triangle Institute, Research Triangle Park, N.C.) to accommodate
the complex sample design of the NHIS and the provided sam-
pling weights.

Am J Psychiatry 163:9, September 2006 ajp.psychiatryonline.org 1577

DISPARITIES IN DEPRESSION DIAGNOSIS

TABLE 1. Rates of Depression by Race and Sex as a Function Clinical Significance Criterion for Depression Diagnosis
All Subjects Women Men
Clinical Significance Criterion Black White Black White Black White
for Depression Diagnosis (N=4,286) (N=26,515) (N=2,696) (N=14,903) (N=1,590) (N=11,612)
Symptoms only 4.08 4.62 5.26 6.08 2.61 3.07
Symptoms and care 1.74*** 2.86 2.27*** 3.91 1.08* 1.73
Symptoms and impairment 1.69* 2.18 2.08* 2.83 1.19 1.49
Symptoms and either care or impairment 2.43** 3.46 3.22** 4.63 1.43* 2.21
*p<0.05. **p<0.01. ***p<0.001.

FIGURE 1. DSM-IV Depression Diagnosis by Race With Clini- Discussion

cal Significance Set at Symptoms Plus Either Receipt of
Care or Level of Impairment
Findings suggest caution in interpreting assessments of
depression that require either receipt of care or self-re-
5
ported impairment as a criterion for a diagnosis. Both
Black
clinical significance criterion substantially lowered esti-
White
4 mates of major depression in African American respon-
dents relative to white/other individuals. This effect might
Rate of Depression

** be explained either by differences in access to mental

3 health care or preferences related to seeking treatment
**
2
* identification of role limitations as being due to psychiat-
1 ric symptoms versus the effects of negative contextual fac-
0 care, then estimates of racial/ethnic differences in unmet
All Subjects Women
*p<0.05.**p<0.01
Results
The sample consisted of 26,515 white/other individuals
and 4,286 African American respondents. As seen in Table
1, when diagnosis of depression was based on symptom
counts alone, there were no differences in prevalence be-
tween white/other subjects compared with African Amer-
ican individuals (risk ratio=1.13, 95% CI=0.951.35). When
operationalized as symptoms plus either receipt of care or
impairment (Figure 1), the clinical significance criterion
differentially resulted in an increased prevalence of de-
pression for white relative to African American subjects
overall (risk ratio=1.43, 95% CI=1.141.78), for women
(risk ratio=1.44, 95% CI=1.131.82), and for men (risk ra-
tio=1.55, 95% CI=1.022.35). The effect was replicated for
receipt of care overall (risk ratio=1.64, 95% CI=1.262.13),
for women (risk ratio=1.73, 95% CI=1.322.26), and for
men (risk ratio=1.60, 95% CI=0.982.61). For endorsement
of impairment, the effect held overall (risk ratio=1.29, 95%
CI=1.011.65) and for women (risk ratio=1.36, 95% CI=
1.041.79), but not men (risk ratio=1.25, 95% CI=0.80
1.95). These bivariate gender and race findings were es-
sentially unaffected when reexamined in multivariate lo-
gistic regression analyses that included covariates for gen-
der, race, age and family income (data not shown).
when it is available. The impact of endorsement of impair-
ment might be attributable to differences in the self-eval-
uation of the effects of psychiatric symptoms or in the
tors associated with race and ethnic identity. Overall,
when diagnosis is not made because of failure to receive
Men
need will be artificially reduced. Specifically, by making
the impairment criterion a requirement for diagnosis, we
may be effectively concluding that at similar levels of
symptoms, African American individuals are less in need
of care for depression than are white/other subjects. The
present data do not allow determination whether racial
differences in the prevalence of depression with the im-
pairment criterion should be interpreted as unmet treat-
ment needs for African American subjects or overutiliza-
tion of care by white individuals, but there is ample
documentation that depression in the community is in
general undertreated (1). Effects were generally found for
both men and women, but the greater prevalence of de-
pression among women held regardless of whether the
impairment criterion was applied. Regardless, these find-
ings call into the question the use of the criteria for clinical
significance when ethnic/racial comparisons are being
made. More generally, these results add to the range of
conceptual and empirically based objections (25) to the
manner in which clinical significance and therefore diag-
nosis are established in the scoring of interview-based
measures of depression used in community surveys. Fur-
ther research is needed to determine the extent to which
depressive symptoms represent need for treatment re-
gardless of reported impairment or treatment, and an ob-
vious first step would be to determine if the clinical signif-
icance criterion improves the prediction of benefit from
established treatments.

1578 ajp.psychiatryonline.org Am J Psychiatry 163:9, September 2006


Received July 15, 2005; revisions received Oct. 28, 2005, and Feb.
6, 2006; accepted Feb. 27, 2006. From the Department of Psychiatry,
School of Social Policy and Practice, University of Pennsylvania
School of Medicine, University of Pennsylvania. Address correspon-
dence and reprint requests to Dr. Coyne, Department of Psychiatry,
University of Pennsylvania Health System, 3400 Spruce St., 11 Gates,
Philadelphia, PA 19106, jcoyne@mail.med.upenn.edu
Supported by NIMH grants 5R01MH061992 and 1K01MH066839.
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