Should African Americans be overtreated for depression the same as whites are? Commentary on Waldman et al (2009)

Contrary to the interpretation that Waldman et al1 provide, we believe that their data point to carelessness with which antidepressants (ADs) are currently being prescribed to both African Americans and whites. These authors examined charts of 864 of 8,028 available patients who had undergone left heart cardiac catheterization. Apparently, records of AD prescriptions and self-report depression inventories were available, but no formal diagnoses of depression. Furthermore, data were available for only 137 African American patients, with only 16 of them receiving an AD. Multivariate regression and subgroup analyses are thus not valid.2

The authors report that 27% of the sample had elevated scores (≥10) on the depression inventory and that an additional 10% of the patients with lower scores on the depression inventory received an AD. From these figures, the authors infer that 38% of the sample had significant depression. However, an elevated score on a self-report depression scale is not itself an indication of the need for AD treatment. In fact, between one tenth and one fifth of patients with scores ≥10 would be found to have major depression,3 suggesting a much lower estimate of the patients appropriate to receive antidepressants. There is thus evidence of gross nonspecific prescribing and overtreatment with ADs in this sample. That 10% of the sample with low depression scores have received an AD is also troubling. Given the poor quality of routine care for depression in general medical settings4 and modest reductions in depression this care is likely to yield,2 it is unlikely that many of these patients were depressed when prescribed an AD or that their low depression scores represent a reduction in symptoms.

Undoubtedly, much depression in medical patients remains undetected and undertreated, but the problem of AD overtreatment is substantial and growing.5 Perhaps, steps could be made to ensure that African Americans have greater access to overtreatment and poor quality depression care. However, we believe it would be much more important that better quality, more nuanced data than what were mustered by Waldman should be gathered to identify breakdowns in the delivery of appropriate prescription of AD and adequacy of follow-up care for depression among all patients, white and minority.