(WITHDRAWN) Racial and Immigration-Based Inequities in Undiagnosed Late-Life Mental Illness Under Universal Coverage

Background: Racial inequities in mental illness and mental health care are well documented. Although late-life mental illness often goes undiagnosed and thus untreated, findings on immigrant mental health are paradoxical: while some argued that immigrants are less likely to have mental illness diagnosis partly attribute to “healthy immigrant effect”, whereas others argued that this phenomenon is explained by medical underuse resulting from post-migration stressors and barriers to access health service. To test both propositions, the study aims to comprehensively investigate racial and immigration-based inequalities in the prevalence of previous diagnosis, self-assessed screening, and undiagnosed mental disorders (for depression and psychological distress respectively) among middle-aged and older Canadians. Disparities in depression treatment were also examined among those with the previous diagnosis.

Methods: Data were obtained from the baseline comprehensive cohorts of the Canadian Longitudinal Study on Aging (2010-2015, n=30,097). The multivariable binary logistics regression model was used to estimate the crude and adjusted odds ratios across 13 nativity/racial groups for 8 mental health outcomes (1. Clinical depression diagnosis; 2. Mood disorders diagnosis; 3. Anxiety disorders diagnosis; 4. Center for Epidemiological Studies-Depression Scale [CES-D10]; 5. Kessler psychological distress scale [K10]; 6. Undiagnosed CES-D10 depression; 7. Undiagnosed K10 Psychological distress; 8. Depression care including antidepressant medication and/or other treatments). A range of risk factors were controlled including demographics (age, sex, marital status), socioeconomic status (family income and education), social support, multi-morbidities and family physician visit in the past 12 months.

Results: Patterns of racial health inequalities differed between self-reported symptoms and physician-diagnosed mental health outcomes: racalized older immigrants (especially South Asian and West Asian immigrants) were less likely than Canadian born whites to report a health professional’s diagnosis of depression (adjusted odds ratio [AOR] range: 0.16-0.53), mood disorders (AOR range: 0.29-0.50) or anxiety disorders (AOR range: 0.27-0.82) . These racialiazed immigrant groups were more likely to screen positive for CES-D depression (AOR range: 1.79-2.54) and K10 psychological distress (AOR range: 1.51-2.26), and consequently they were more likely to have undiagnosed depression (AOR range: 2.13-3.53) and undiagnosed psychological distress (AOR range: 1.57-3.48), compared to their Canadian-born white counterparts. Latin American (AOR=0.14; 95%CI: 0.04-0.41), East Asian (AOR=0.37; 95%CI: 0.16-0.89) and West Asian immigrants (AOR=0.41; 95%CI: 0.17-0.99), aboriginals (AOR=0.24; 95%CI: 0.11-0.54) and racialized individuals born in Canada (AOR=0.38, 95%CI: 0.15-0.94) were less likely to be treated for depression. White immigrants were comparable to Whites born in Canada on all these measures (p>0.05)

Conclusions and Implications: Despite universal health coverage, the burden of mental illness disproportionately affects racialized older adults. At the research level, the findings suggest that the “healthy immigrant advantage” identified based upon a health professional’s diagnosis may be erroneous. It highlights the issue of under-detection by health providers and under-recognition of mental health problems by minority older people. At the practice level, clinicians should thoroughly screen racialized elders for mental illness using a standardized rating scale. At the policy level, a culturally sensitive mental health system and geriatric workforce are required to unmet mental health needs among racialized older immigrants.