How Do Race, Gender, and Education Impact Depression Care in Brazil?

What you need to know

• Women, Black individuals, and those with lower education levels had higher rates of probable depression but lower access to diagnosis and care in Brazil.
• There was a major bottleneck in the first step of depression care - being diagnosed by a health professional. Black individuals were significantly less likely to receive a depression diagnosis.
• The Brazilian healthcare system appears to perpetuate inequities, with multiply marginalized groups (e.g. low-education Black women) facing the greatest barriers to depression care.

Understanding depression and its treatment in Brazil

Major depressive disorder (MDD) is the most common mental illness worldwide. It’s a chronic condition characterized by severe sadness, hopelessness, lack of interest and energy, and thoughts of death. MDD typically starts by age 18 and involves recurring episodes throughout life. Treating depression usually requires a combination of psychotherapy and medication.

Managing depression is especially challenging in countries like Brazil, where access to quality mental healthcare is limited, particularly for marginalized groups. Previous research has found that only about one-quarter of Brazilian adults with depression had been diagnosed by a doctor, and less than one-fifth were taking antidepressants.

This study aimed to examine how social factors - specifically race, gender, and education level - affect access to depression care in Brazil’s healthcare system. The researchers were particularly interested in looking at how these factors intersect and create compounded disadvantages for certain groups.

How the study was conducted

The researchers analyzed data from the 2019 Brazilian National Health Survey, which included over 87,000 respondents aged 18 and older. They looked at four key steps in what they call the “depression care cascade”:

1. Having probable depression (based on a screening questionnaire)
2. Being diagnosed with depression by a health professional
3. Having regular healthcare visits for depression
4. Accessing specialized treatment for depression (like therapy or medication)

They examined how race (white vs. Black), gender (men vs. women), and education level (high vs. low) were associated with each of these steps. They also looked at how these factors intersected - for example, comparing low-education Black women to high-education white men.

Key findings on depression prevalence and diagnosis

The study found some important disparities in who experiences depression and who receives a diagnosis:

• About 11.5% of respondents had probable depression based on the screening questionnaire.
• Women were much more likely to have probable depression than men (15.8% vs. 6.6%).
• Those with lower education levels had slightly higher rates of probable depression compared to those with higher education (12.8% vs. 10.5%).
• There was no significant difference in depression rates between white and Black respondents.

However, when it came to being diagnosed by a health professional, some concerning inequities emerged:

• Only 35.8% of those with probable depression had been diagnosed by a health professional.
• Black individuals were significantly less likely to receive a depression diagnosis compared to white individuals (32.4% vs. 40.4%).
• Women were more likely to be diagnosed than men (38.5% vs. 28.5%).
• Those with higher education were slightly more likely to be diagnosed than those with lower education (37.0% vs. 34.5%).

This reveals a major bottleneck in the first step of depression care - being diagnosed. Black individuals in particular face barriers to having their depression recognized and diagnosed by healthcare providers.

Access to ongoing depression care

For those who did receive a depression diagnosis, the study found fewer disparities in accessing ongoing care:

• About 48.7% of those diagnosed had access to regular healthcare services for depression.
• There were no significant differences by race, gender, or education level in accessing regular services.
• Nearly all (97.7%) of those with regular services had access to specialized depression treatment like therapy or medication.
• Again, there were no major disparities in access to specialized treatment.

This suggests that the biggest inequities occur at the diagnosis stage. Once people enter the mental healthcare system, they generally have similar access to ongoing treatment regardless of social factors.

The impact of intersecting disadvantages

The researchers also examined how race, gender, and education intersect to create compounded disadvantages for certain groups. Some key findings:

• Low-education Black women had the highest odds of probable depression compared to high-education white men.
• However, high-education white women were the most likely to receive a depression diagnosis.
• Low-education Black men were the least likely to be diagnosed with depression.

This reveals complex patterns of inequity. The groups with the highest mental health needs (like low-education Black women) are not the ones most likely to have their depression recognized and diagnosed by the healthcare system.

What this means for depression care in Brazil

The study’s findings point to some concerning trends in Brazil’s mental healthcare system:

• There is an “inverse care law” at work - those with the greatest mental health needs are the least likely to have those needs recognized and addressed by healthcare providers.
• The system appears to perpetuate existing social inequities, overlooking the mental health struggles of multiply marginalized groups.
• The biggest bottleneck is at the diagnosis stage - many people with depression, especially Black individuals, are not having their condition recognized by health professionals.

These results suggest that Brazil’s healthcare system needs to take steps to provide more equitable mental health care, including:

• Improving depression screening and diagnosis, especially for Black patients and other marginalized groups
• Training healthcare providers to recognize depression in diverse populations and combat potential racial biases
• Increasing overall mental health resources and access, particularly in underserved communities
• Addressing the broader social and economic factors that contribute to higher depression rates among disadvantaged groups

Conclusions

• Women, Black individuals, and those with lower education face significant barriers to having their depression diagnosed, despite often having higher rates of depression.
• The Brazilian healthcare system perpetuates existing social inequities in mental health care access.
• Improving equitable screening and diagnosis of depression should be a priority to reduce mental health disparities.
• More research is needed to understand the complex intersections of social factors that contribute to depression risk and care access.