Patients seeking treatment for depression, those with lower incomes and educational backgrounds, and those who belong to minorities tend to have poorer treatment outcomes, even when they receive equal access to treatment, according to a new study from the University of Cincinnati.
Led by Jeffrey Mills, PhD, and Jeffrey Strawn, MD, UC’s cross-university collaborative research was recently published in the journal Psychiatric Services.
Strawn, a professor in the Department of Psychiatry and Behavioral Neuroscience at UC College of Medicine and adolescent psychiatrist at UC Health, said previous research has concluded that people seeking treatment for depression with lower income and less education perform poorly due to lack of access to quality health care, but it is difficult to isolate socioeconomic factors as they are often intertwined.
The research team analyzed data from a very large clinical trial called CO-MED, which involved 665 patients seeking treatment for their depression. In the randomized study, all patients had equal access to treatment, with no differences based on health insurance or income.
After controlling for gender, age and type of treatment after 12 weeks of antidepressant treatment in the study, the team’s analysis found that non-white patients improved by 11.3% less compared to white patients. Unemployed patients saw a 6.6% less improvement compared to working patients. Compared to patients in the 75th percentile of the income distribution, patients with an income in the 25th percentile reduced the improvement by 4.8%.
Strawn noted that the results are still preliminary, but he was particularly interested that patients without a college degree showed a 9.6% lower improvement compared to college graduates.
“We think about these things in terms of access, we think about them in terms of income inequality, and I realize education aligns with those, but just having a college degree and at the same time considering all these other factors still had a significant impact,” Strawn said.
The researchers also looked at the effect of combining socioeconomic factors, since the individual factors are often correlated, Mills said. Patients who were non-white, unemployed without a degree, and had an income in the 25th percentile showed a 26% less improvement compared to patients who were white, had a college degree, and had an income in the 75th percentile.
Mills said the results do not negate the fact that lack of access has an impact on treatment outcomes, but they do show the importance of including a patient’s home environment when analyzing treatment effectiveness.
“If you go home to an affluent area with a highly educated parent or spouse, then arguably you’re in a much better environment for effective treatment than if you go to a poor area with different problems,” he said Carl H. Lindner College of Business at UC.
Strawn said other research suggests patients in resource-poor settings may experience greater chronic variable stress, meaning high levels of stress in a pattern that’s intermittent and difficult to predict. Other studies suggest that chronic variable stress has a worse effect on patients than chronic ongoing stress, which is more constant, he said.
“So that’s like, ‘I’ve been able to pay my rent this month, but I’m not sure I’ll be able to do that next month. And I have a job right now, but I don’t know if I’ll be doing that next month,'” Strawn said. “So it’s just the impact of all of those things, plus maybe relatives or kids who have fewer educational resources, or other work-related stress, or maybe other health issues, and you still run into the same barriers to entry and costs and support there.”
The study results have the potential to influence clinical trials by designing studies that pay more attention to socioeconomic variables that may have previously been overlooked, Strawn said.
“If we don’t control for these variables, which we often don’t do in our clinical trials because of population differences, we may miss the discovery of an effective treatment because its effect is obscured,” Strawn said. “So it can potentially jeopardize our treatment development if these factors are not taken into account.”
Strawn said those treating patients on a daily basis could use knowledge from the study in a simpler approach. While removing barriers to entry to treatment is important, clinicians must also recognize that a patient’s socioeconomic environment can affect their ability to do better with treatment when measuring progress and creating future treatment plans.
Mills said the research also has important implications for how economic policies are designed and implemented, such as the recently passed infrastructure bill or the ongoing discussions about the minimum wage. The impact of a policy on a person’s socioeconomic environment, and consequently their mental health, is usually not considered, he said.
“Someone with a higher wage has an opportunity to improve their socioeconomic status and environment, so they’re definitely less likely to develop mental health problems,” he said. “When people with higher socioeconomic status develop mental health problems, we show that they are more likely to improve if treated.”
science in the team
In the past, two researchers with different disciplines at different colleges within a university may not have collaborated on such research, but the collaboration shows the benefits of what is known as team science, a transdisciplinary research approach.
Strawn explained that traditional multidisciplinary research often looks like a psychiatrist, a neurologist, and a psychologist all working on a project within the College of Medicine. While that has its place, Team Science is interdisciplinary and involves vastly different sets of expertise, concepts, and approaches.
“We think of multidiscipline as sort of like a fruit salad, where you have your grapes and you have your bananas, but everything is still different,” Strawn said. “And then you have your transdisciplinarity, where things are really mixed up and it’s difficult to tell whose contribution is whose. This is probably more the fruit smoothie of disciplinary integration. I think hopefully we’ve achieved that.”
Mills said he had previously seen colleagues who were expected to work closely together who never published work together because their skills were too similar and they didn’t need each other to advance. Alternatively, Mills and Strawn have an interest in each other’s areas of expertise and bring different, complementary skills to the research.
“It’s more than just multidisciplinary, because when I sit down with my colleagues, we still have very similar training. We use the same jargon, we have similar ideas,” Mills said. “There’s not the same cross-fertilization when you step out of your field and think about other issues and give each other ideas and concepts that you might not have thought of.”
Going forward, the researchers plan to continue the research by combining data from other depression studies to produce more meaningful results with a larger data set.
subject of research
Socioeconomic predictors of treatment outcomes in adults with major depressive disorder
Article publication date
March 31, 2022