Major Depressive Episode Severity Among Adults from Marginalized Racial and Ethnic Backgrounds in the US

Depression is the leading cause of disability and disease burden in the US.^1,2 Research using the National Comorbidity Survey (fielded 1990-1992) showed that while lifetime and past-year rates of major depressive disorder were lower among individuals from minoritized racial and ethnic groups compared with White adults,³ major depressive disorder persistence was greater for Black and Latino adults.³ Analysis of the National Survey of American Life (fielded 2001-2003) found similar or lower major depressive disorder prevalence among Black adults compared with White adults but greater major depressive disorder chronicity, severity, and disability.⁴ We provide an update of these findings, analyzing nationally representative data to estimate differences in major depressive episode (MDE) prevalence, persistence, and severity among racial and ethnic groups.

Five years of cross-sectional data (2015-2019) from the National Survey on Drug Use and Health were pooled for adults (age ≥18 years). The National Survey on Drug Use and Health is a nationally representative survey of noninstitutionalized US civilians, with a 70% to 80% response rate that enables identification of mental illness using validated DSM-based diagnostic instruments.⁵ We defined persistence as experiencing lifetime and past-year MDE.³ Severity was defined as experiencing past-year MDE with very severe impairment, based on Sheehan Disability Scale scores.⁵ Analysis of these deidentified, publicly available data was considered exempt from institutional review board review per institutional and federal regulations. Age- and sex-adjusted logistic regression models were estimated to assess racial and ethnic differences in MDE outcomes. Analyses completed in Stata version 16 (StataCorp) accounted for complex survey design to generate nationally representative estimates. Analysis took place from March to June 2021.

A total of 203 295 individuals were included in this analysis. Black (n = 27 081), Latino (n = 37 015), and Asian (n = 10 275) adults had lower rates of lifetime (8.9%; 95% CI, 8.6-9.4; P < .001 vs 10.2%; 95% CI, 9.7-10.7; P < .001 vs 8.3%; 95% CI, 7.7-9.3; P < .001, respectively) and past-year (5.4%; 95% CI, 5.1-5.7; P < .001 vs 5.7%; 95% CI, 5.3-6.1; P < .001 vs 4.1%; 95% CI, 3.7-4.8; P < .001, respectively) MDE than White adults (n = 128 924) (Table 1). Compared with White adults, Black adults had higher rates of MDE persistence (1799 of 2870 [61%]; 95% CI, 58.3-62.8 vs 13 013 of 23 781 [50%]; 95% CI, 49.1-51.1; P < .001) and severity (410 of 1799 [24%]; 95% CI, 21.6-26.3 vs 2379 of 13 013 [19%]; 95% CI, 18.0-19.8; P < .001), Latino adults had higher rates of persistence (2761 of 4621 [56%]; 95% CI, 53.4-58.9 vs 13 013 of 23 781 [50%]; 95% CI, 49.1-51.1; P < .001) and comparable rates of severity, and Asian adults had comparable rates of MDE persistence and lower rates of severity (98 of 616 [11%]; 95% CI, 7.87-13.74 vs 2379 of 13 013 [19%]; 95% CI, 18.02-19.84; P < .010). Noticeable differences existed between racial and ethnic groups in age and sex distributions.

Compared with White adults (Table 2), Black adults had higher odds of MDE persistence (odds ratio, 1.4; 95% CI, 1.3-1.6; P < .001) and severity (odds ratio, 1.3; 95% CI, 1.2-1.6; P < .001), Latino adults had comparable odds of MDE persistence and severity, while Asian adults had similar odds of MDE persistence and lower odds of MDE severity (odds ratio, 0.5; 95% CI, 0.4-0.7; P < .010).

This nationally representative data analysis identified that Black adults continue to experience greater MDE persistence and severity, Latino adults experience comparable MDE persistence and severity, and Asian adults had comparable MDE persistence but lower severity compared with White adults. Consistent with prior research, minoritized racial and ethnic groups had lower MDE prevalence than White adults. Our findings update prior research,^3,4 raising concern about the continued disease burden experienced by Black adults. Greater experiences of discrimination, racism, and disparities in access to and quality of mental health treatment may partly explain our findings.⁶ These pathways are amenable to clinical and policy intervention that could buffer the links between mental illness, disability, and premature death.⁶

This study has some limitations. The National Survey on Drug Use and Health excludes persons institutionalized or lacking a permanent address. Data are cross sectional and based on survey respondents’ self-report.⁵

Culturally responsive and nondiscriminatory outreach is needed to improve mental health service use among individuals from minoritized racial and ethnic groups.⁶ Clinicians practicing patient-centered treatment that support active patient participation and openness to understanding patient experiences with and interpretation of mental illness can improve mental health care. It is important that clinicians acknowledge and be sensitive to patients’ prior experiences with discrimination and trauma stemming from medical system interactions, which may contribute to treatment nonadherence and exacerbation of mental illness.⁶ These considerations are especially salient as we continue to endure the COVID-19 pandemic, which has disproportionately affected minoritized racial and ethnic groups and elevated their need for mental health treatment.

Corresponding Author: Michael William Flores, PhD, MPH, Health Equity Research Lab, 1035 Cambridge St, Ste 26, Cambridge, MA 02141 (mwflores@cha.harvard.edu).

Accepted for Publication: July 1, 2021.

Published Online: September 8, 2021. doi:10.1001/jamapsychiatry.2021.2485

Author Contributions: Dr Flores had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Flores, Rodgers, Cook.

Acquisition, analysis, or interpretation of data: Flores, Moyer, Cook.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Flores, Rodgers, Cook.

Statistical analysis: Flores, Cook.

Obtained funding: Cook.

Administrative, technical, or material support: Flores, Moyer, Rodgers.

Supervision: Flores, Cook.

Conflict of Interest Disclosures: Dr Cook reports grants from Humana outside the submitted work.

Funding/Support: This work was supported by the National Institute on Minority Health and Health Disparities (grant R01MD010456; principal investigators, Drs Fung and Cook).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.