Some people with depression may refuse treatment because of the associated stigma, but the majority may go untreated simply because it is too expensive, according to the findings of an international study.

“A lot of people think of stigma as being a big barrier” to depression treatment, Dr. Gregory E. Simon, a researcher with Puget Sound’s Group Health Cooperative in Seattle, Washington told Reuters Health. Yet, the expense of being treated for depression “may be a much more important issue than stigma,” he said.

Data from the United States and Western Europe suggest that improvements are needed in how depression is managed in the primary care setting, according to report published in the American Journal of Psychiatry.

Studies show that many affected patients go unrecognized, while those who are identified as having depressive symptoms do not always get the best treatment. However, less is known about how effectively depression is treated in areas outside the US and Western Europe.

The current study’s findings are based on information from 1,117 people who were identified as having current depressive disorder in primary care centers in Spain, Israel, Australia, Brazil, Russia and the United States.

The study participants were interviewed about their depression, other physical conditions, and what they perceived as barriers to treatment. Three and nine months after doctors were notified about these patients’ probable depression, the participants reported the type of mental health services they had received.

The highest proportion of study participants treated with antidepressants during the nine-month period was found in the United States, Simon and his colleagues report. Thirty-eight percent of patients in Seattle, Washington, said they received some type of antidepressant therapy. Yet, only 33 percent received an effective dose.

In Barcelona, Spain, 21 percent of study participants received antidepressant treatment, and most (20 percent) received an adequate dose.

Eleven percent of people in Melbourne, Australia, 11 percent of those in Porto Alegre, Brazil, and four percent of those in Be’er Sheva, Israel were also given antidepressants and nine, ten and two percent, respectively, were given effective doses.

In St. Petersburg, Russia, however, none of the study participants reported receiving antidepressants, the report indicates.

In other findings, the proportion of patients receiving any type of specialty mental health care ranged from nearly 30 percent of subjects in Melbourne, Australia, to three percent of those in St. Petersburg.

When asked what barred them from receiving treatment, some patients indicated that the treatment was embarrassing, others said that seeking treatment might compromise potential job opportunities, and still others said the depression treatment made them feel sick.

However, the most commonly reported barrier to depression treatment was the out-of-pocket costs, the team found.

Across the six countries, nearly 40 percent of patients said they could not afford to be treated for depression. This barrier to treatment was cited by 75 percent of study participants in Russia and 32 percent of those in Australia, the two countries where patients are required to pay the full cost of prescription drugs.

The financial strain was also felt in countries that required co-payments, as indicated by the 40 percent of patients in Brazil, 38 percent of patients in the United States, 26 percent of patients in Israel and 24 percent of patients in Spain, who said depression treatment is not affordable.

Thus, “the probability of treatment may be more influenced by characteristics of health care systems than by the clinical characteristics of individual patients,” write Simon and his colleagues.

In other words, although the lack of depression treatment among traditionally disadvantaged groups is often attributed “to stigma or cultural factors,” which are difficult to change, many times the underlying reason is “really about economic factors,” Simon said.

Eli Lilly and Company funded the study.

SOURCE: American Journal of Psychiatry, September 2004.