Depressed Americans Forgo Treatment

Many people, especially the poor, get used to being sad and hopeless. They don't think they have an illness and don't realize they can get treated.

More than 8 percent of American adults had a serious bout of depression in 2020, according to government figures. That amounts to about 21 million people. In 2021, the shutdowns that kept people at home and worrying about COVID-19 made things worse, though rates of depression and anxiety then improved.

Even before the pandemic, far too few depressed Americans were getting treatment — only about a third. That was true even for those with a severe problem.

The reasons more Americans don’t seek treatment for depression are complex, says Carol Landau, PhD, a practicing psychologist and professor at Brown University. Many assume they can’t get help.

“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 woman 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.”

 

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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 — calling 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.”

Historically, people living below the poverty line have been about 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 show up among teenage girls — more than 25 percent. About 17 percent of young people, from 12 to 25, —suffer from depression. Adult women (10.5 percent) are more likely to report major depression than men (6.2 percent).

Higher depression rates among women have 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 nearly 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.”

Suicidal impulses can lead to attempts quickly, often from a pileup of problems. Some people make attempts even when they woke up that morning with no intention of dying.

High out-of-pocket deductibles, common under the Affordable Care Act, 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.”

 

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