The more you need, the less you get: Intersectionality and the inverse care law in the Brazilian depression care cascade

ABSTRACT

Substantial research has shown that the population distribution of major depressive disorder (MDD) is strongly influenced by race, gender, and socioeconomic position. However, a deeper understanding of inequities in access to care for MDD according to these social markers is yet to be reached. We use data from the 2019 Brazilian National Health Survey, which includes 87,187 respondents aged 18 years and over, to test two hypotheses derived from the inverse care law: women, Black, and low-education respondents have higher frequencies of MDD, but lower access to each step of the depression care cascade, including diagnosis by a health professional, regular healthcare visits, and access to specialised treatment (H1); low-education Black women show the highest MDD frequency and the lowest access to care across the entire cascade (H2). Partially supporting H1 and H2, our results reveal a bottleneck in the first step of the depression care cascade. While no racial inequities were observed in the MDD prevalence, Black individuals were less likely than whites to be diagnosed by a health professional (OR 0.74). Women (OR 2.64) and low-education (OR 1.18) were more likely to have probable MDD in relation to men and high-education respondents, respectively, but only women (OR 1.58) were more likely to be diagnosed. Low-education Black women were equally more likely to have probable MDD (OR 3.11) than high-education white men. Conversely, high-education white women emerged as the most likely to be diagnosed with MDD (OR 1.63). Our findings suggest the inverse care law applies to the depression care cascade in Brazil through indication that its healthcare system perpetuates a multilayered system of oppression that overlooks multiply marginalised individuals. We also show that adequate screening by health care professionals should mitigate the complex patterns of inequity revealed by our study.

KEYWORDS:

• Depression
• healthcare disparities
• mental health services
• race
• gender
• socioeconomic factors
• Brazil

Acknowledgements

Special gratitude to all the participants of the 2019 National Health Survey and the team members who carried out this survey. Support to write this article was given to Dr Helena Mendes Constante by the National Council for Scientific and Technological Development (CNPq) through a Postdoctoral Fellowship (Process number 150275/2020-0). Dr João Luiz Bastos was partially supported by the Brazilian National Research Council (Research Grant 304503/2018-5). Dr Milagros Ruiz was supported by two European Commission Horizon 2020 research grants: External and Internal Human Exposure in Urban EXposome (URBAN X) (no. 857340) and the Promoting Mental Wellbeing in the Ageing Population: Determinants, Policies and Interventions in European Cities (MINDMAP) (no. 667661).

Disclosure statement

No potential conflict of interest was reported by the authors.

Declaration of interest statement

The authors have no conflict of interest to disclose.

Additional information

Funding

This work was supported by CNPQ: [Grant Number 150275/2020-0,304503/2018-5]; Horizon 2020: Promoting Mental Wellbeing in the Ageing Population: Determinants, Policies and Interventions in European Cities (MINDMAP): [Grant Number 667661]; Horizon 2020: External and Internal Human Exposure in Urban EXposome (URBAN X): [Grant Number 857340].