Quality of life and functioning of Hispanic patients with Major Depressive Disorder before and after treatment

Highlights

• Hispanics and non-Hispanics reported similar depression at entry and exit.

• Hispanic had worse QOL at entry and exit (not after controlling for baseline QOL).

• Significant improvements in QOL, functioning, and depression following treatment.

• Hispanics were less likely to have private insurance compared to non-Hispanics.

Abstract

Background

Similar rates of remission from Major Depressive Disorder (MDD) have been documented between ethnic groups in response to antidepressant treatment. However, ethnic differences in functional outcomes, including patient-reported quality of life (QOL) and functioning, have not been well-characterized. We compared symptomatic and functional outcomes of antidepressant treatment in Hispanic and non-Hispanic patients with MDD.

Methods

We analyzed 2280 nonpsychotic treatment-seeking adults with MDD who received citalopram monotherapy in Level 1 of the Sequenced Treatment Alternatives to Relieve Depression study. All subjects (239 Hispanic, 2041 non-Hispanic) completed QOL, functioning, and depressive symptom severity measures at entry and exit.

Results

Hispanic participants had significantly worse QOL scores at entry and exit (p < 0.01). However, after controlling for baseline QOL, there was no difference between Hispanic and non-Hispanic patients’ QOL at exit (p = 0.21). There were no significant between-group differences at entry or at exit for depressive symptom severity or functioning. Both groups had significant improvements in depressive symptom severity, QOL, and functioning from entry to exit (all p values < 0.01). Patients with private insurance had lower depressive symptom severity, greater QOL, and better functioning at exit compared to patients without private insurance.

Limitations

This study was a retrospective data analysis, and the Hispanic group was relatively small compared to the non-Hispanic group.

Conclusions

Hispanic and non-Hispanic participants with MDD had similar responses to antidepressant treatment as measured by depressive symptom severity scores, quality of life, and functioning. Nevertheless, Hispanic patients reported significantly worse quality of life at entry.

Introduction

Major Depressive Disorder (MDD) affects 350 million people worldwide and is the leading cause of disability among mental health disorders (World Health Organization, 2017). MDD is associated with greater morbidity and mortality, both as a standalone diagnosis and in the context of other medical illnesses such as coronary heart disease, myocardial infarction and HIV/AIDS (Fawcett, 1993, Leserman, 2008, Pence, 2009, Whooley et al., 2008). Patients with MDD present symptoms of depression and impairments in functioning and quality of life (QOL) (Ishak et al., 2011). QOL is an individual's perception and satisfaction of their psychological, social and physical health (World Health Organization, 1997). In recent years, there has been increased attention on enhancing QOL, as it is strongly correlated with greater MDD symptom severity via socio-demographic factors such as employment, education, race and medical insurance status (Trivedi et al., 2006). Additionally, a number of studies have demonstrated that antidepressant monotherapy improves QOL in MDD, as measured by various validated assessment tools (Chokka and Legault, 2008, Demyttenaere et al., 2008, Ishak et al., 2011, Kocsis et al., 2002, Steiner et al., 2017).

The Hispanic population is currently the largest ethnic minority in the United States, with MDD rates similar to non-Hispanic Whites (Murray and Lopez, 1997), although some data suggest a higher prevalence among Hispanics (Blazer et al., 1994, Dunlop et al., 2003). Despite the high burden of MDD, most studies suggest that Hispanics are less likely than non-Hispanic Whites to seek mental health care and are also less likely to receive appropriate treatment for depression (Simpson et al., 2007, Young et al., 2001). Several studies have identified factors that may predispose Hispanics to disparities for MDD treatment, including language and health literacy barriers, lower cultural acceptability and reduced adherence to antidepressants, and a higher uninsurance rate, as compared to non-Hispanic Whites (Harman et al., 2004, Lagomasino et al., 2005, Miranda and Cooper, 2004, Schraufnagel et al., 2006, Young et al., 2001). In fact, the uninsurance rate is 2.6 times higher for Hispanics than non-Hispanic Whites and was correlated to worse health outcomes (Denavas-Walt et al., 2011). Additionally, Hispanics are less likely to have private insurance coverage, and may contribute to MDD treatment disparity, given that publicly insured patients have greater severity of depression, greater functional impairment, and lower life satisfaction, as compared to privately insured patients (Lesser et al., 2005). Furthermore, as the demographics of United States continue to change, there are other sociocultural variables that often contribute to racial marginalization for Hispanics, such as public education disparities (Mordechay and Orfield, 2017). Numerous factors related to education inequality can have a significant influence on patients’ ability to gain access to healthcare, and navigate the healthcare system, which may ultimately affect health outcomes in the landscape of American mental-health for Hispanics.

Previous studies examining antidepressant treatment response in Hispanics with MDD demonstrated similar rates of symptom remission compared to other ethnic groups (Lesser et al., 2007, Lesser et al., 2011), but few studies have compared functional outcomes such as QOL and functioning by ethnicity. A secondary analysis reported these functional outcomes among ethnicities, the Combining Medications to Enhance Depression Outcomes (CO-MED) study, which determined that symptom remission, QOL and functioning outcomes were similar among Hispanics, Whites, and Blacks, after treatment with single or combined antidepressant therapy (Lesser et al., 2011). The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, which was funded by the National Institutes of Health (NIH), remains the largest prospective randomized, multicenter, multistep clinical trial examining treatment efficacy for nonpsychotic individuals with persistent MDD in outpatient settings to date (Fava et al., 2003, Rush et al., 2004). The STAR*D study also contains the largest number of ethnic minority patients in a single clinical trial for depression, and includes systematic collection of patient-reported QOL, functioning, and depressive symptom severity data. The STAR*D study was designed to ascertain the efficacy of various antidepressant treatments for MDD in patients who did not respond to initial treatment of MDD with citalopram, a first-line selective serotonin reuptake inhibitor (SSRI) antidepressant.

In light of an increasing recognition of QOL as an important clinical outcome, this study presents a formal comparison of QOL, functioning, and depressive symptom outcomes in the STAR*D trial between Hispanic and non-Hispanic individuals with MDD, before and after citalopram monotherapy. Based on the data suggesting similar symptom remission rates between Hispanics and other ethnic groups with MDD treated with antidepressants, we hypothesized that Hispanic patients would have comparable improvements in QOL and functioning in response to antidepressant monotherapy compared to non-Hispanic patients.