that evidence-based therapies for depression can be effective when appropriately tailored for ethnic and disadvantaged populations.

BARRIERS TO TREATMENT

Despite the efficacy of depression treatments, this disorder is under-treated. Adults experiencing major depression are often not inclined to seek treatment for their illness. Barriers for pregnant and postpartum mothers with depression are similar to those in the general population, as described in Chapter 1, but they also include the tendency to normalize depressive symptoms and to dismiss them as self-limiting and the fear of losing one’s baby (Dennis and Chung-Lee, 2006). The diagnosis of postpartum depression is also complicated by the overlap of common postpartum symptoms with symptoms of depression (e.g., lack of sleep, change in eating). And, racial, ethnic, and non-English speakers are also less likely to seek or receive quality interventions (see Alegría et al., 2008).

Furthermore, the lack of insurance or underinsurance, in which the benefit package lacks comprehensive insurance, limits the access and use of mental health services for those seeking depression care. Often those with coverage are limited because of high cost-sharing methods (i.e., copayments, premiums) and benefit restrictions (i.e., annual or lifetime limits) (U.S. Surgeon General, 1999). However, recent efforts regarding mental health parity have picked up momentum at the federal level, with cooperation by state agencies. For example, the passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (P.L. 110-343) requires employers with 50 or more employees to offer health plans with mental health and substance abuse disorders coverage equal to all other medical and surgical benefits covered by the plan.

Barriers to treatment operate at both institutional level and sociocultural levels. This categorization is not mutually exclusive, however, and there exists substantial mutual influence and interaction between the two realms. At the institutional level, lack of health insurance overall and lack of insurance coverage (and the associated high cost of care) for mental health services, referral system fragmentation, and the limited availability of mental health specialists are the primary factors limiting vulnerable populations’ access to depression treatment (Das et al., 2006; Kung, 2004; Lazear et al., 2008; Thompson, Bazile, and Akbar, 2004; Van Voorhees et al., 2007; Wong et al., 2006). When they do receive depression treatment, racial and ethnic minority groups are more likely to seek and receive mental health care from the primary care setting. However, primary care physicians are not typically trained in the intricacies of diagnosing depression or any other mental illnesses, resulting in the underrecognition, diagnosis, and treatment of depression (Van Voorhees et al., 2007). The lack of ap-



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