Racial Inequality in the Prevalence of Symptom-Based Depression Versus Self-Reported Medical Diagnosis in Brazil

Journal of Racial and Ethnic Health Disparities https://doi.org/10.1007/s40615-025-02397-7 Racial Inequality in the Prevalence of Symptom‑Based Depression Versus Self‑Reported Medical Diagnosis in Brazil Thais Cristina Marquezine Caldeira5 · Luiza Eunice Sá da Silva1 · Rafael Moreira Claro2 Jorginete de Jesus Damião3 · Daniela Silva Canella4 · Taciana Maia de Sousa3 · Received: 8 December 2024 / Revised: 20 February 2025 / Accepted: 14 March 2025 © The Author(s) 2025 Abstract A cross-sectional study was conducted with Brazilian adults from the 2019 Pesquisa Nacional de Saúde (PNS 2019; National Health Survey, in English) who self-declared race/skin color white or black (n = 87,187), to investigate racial inequality in the prevalence of symptom-based versus self-reported depression. Symptom-based depression was screened using the Patient Health Questionnaire-9 (cutoff ≥ 10), while medical diagnosis was self-reported. Prevalence of agreement (presence of medical diagnosis among those with symptoms) and disagreement (absence of medical diagnosis among those with symptoms) were compared according to race/skin color. The Odds Ratio (OR) for the association between both depression indicators and race/skin color were estimated by Logistic regression adjusted by socioeconomic variables. The black population had a higher prevalence of symptom-based depression than medical diagnosis (11.0% versus 8.6%; 2.5 percentual points (pp)), with greater differences among younger adults (6.0 pp), without a partner (3.6 pp), with lower income (3.9 pp), education (3.0 pp), less developed regions (north: 3.6 pp; northeast: 4.2 pp) and those with recent access to medical care (4.5 pp). The white population had a higher prevalence of medical diagnosis than symptom-based depression (10.6% versus 12.5%; -1.9 pp), with greater differences between those with higher income (-7.4 pp), education (-4.5 pp) and from south region (-6.0 pp). Disagreement was higher among black individuals while agreement was higher among white, with significant inequality among women for both agreement (33.5% in black versus 41.7% in white) and disagreement (66.5% in black versus 58.3% in white). The black population had a lower chance of having medical diagnosis of depression (OR 0.77; 95%CI 0.70–0.84) than white, regardless of socioeconomic variables. Racial inequality was identified in the prevalence of symptom-based versus self-reported depression, with greater inequality among women and those with lower income and education. Keywords Depression · Health inequities · Black people · Racial groups · Health surveys Introduction * Thais Cristina Marquezine Caldeira 1 Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, RS, Brazil 2 Nutrition Department, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil 3 Social Nutrition Department, Rio de Janeiro State University, Rio de Janeiro, RJ, Brazil 4 Applied Nutrition Department, Janeiro State University, Rio de Janeiro, RJ, Brazil 5 Postgraduate Program in Public Health, Federal University of Minas Gerais, Av. Prof. Alfredo Balena, 190, Santa Efigênia, Belo Horizonte, MG 19030130‑100, Brazil Mental disorders are one of the main contributors to the global disease burden [1], constituting a significant public health challenge worldwide. Depression, as part of this group of illnesses, is noteworthy for its increasing prevalence, which has risen from 170.8 million cases in 1990 to 279.6 million cases in 2019 worldwide [1]. Public health interventions at the population level require continuous surveillance of the health conditions and impact of diseases on the population and healthcare systems [2, 3]. While it may not be feasible to diagnose depression through population surveys, gathering information on previous diagnoses provided by healthcare professionals or collecting data on subjective symptoms, such as alterations in thoughts, behaviors, and mood, using Vol.:(0123456789) Journal of Racial and Ethnic Health Disparities validated screening tools, can contribute to the assessment of the panorama of depression in a population [2, 4]. The use of self-reported information is an important strategy for epidemiological surveillance [5]. Therefore, the collection of information on self-reported medical diagnosis of depression is already well established in health surveys, such as the Behavioral Risk Factor Surveillance System (BRFSS) in the United States [2] and Surveillance System of Risk and Protection Factors for Chronic Diseases by Telephone Survey (Vigitel) [6] and the 2019 Pesquisa Nacional de Saúde (PNS 2019; National Health Survey, in English) in Brazil [7]. The use of the Patient Health Questionnaire-9 (PHQ9) scale, for example, is a validated method for collecting information about depression at a population level [2, 8]. The PHQ9 tracks the presence of nine components of the “Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)”, based on symptoms observed by a healthcare professional or reported by the patient, making it possible to identify depressive disorders larger and clinically significant (especially for a PHQ-9 ≥ 10) [2, 8]. The investigation of depression at a population level in Brazil has been carried out in 2013 and 2019 by the PNS [7]. According to this survey, the prevalence of selfreported medical diagnosis of depression in the adult population increased in this period from 7.6% to 10.2%, with a greater increase in the period among women, young people, with higher incomes and education [9]. The importance of considering social determinants when examining mental health has been reported by some studies [4, 8–10], highlighting that socioeconomic disparities may lead to an underestimation of the prevalence of depression in vulnerable populations, especially in the context of Brazil [4, 9]. One of the key factors influencing medical diagnoses of depression is the access to healthcare services, as individuals with limited access to medical care are less likely to receive a formal diagnosis, despite experiencing depressive symptoms [11]. This dependence on healthcare access can lead to disparities in reported prevalences, particularly among groups facing socioeconomic disadvantages, where barriers such as affordability, geographic distribution of services, and cultural stigmas may prevent diagnosis and treatment [11]. A worse scenario can still be observed among the black population (individuals who self-declared race/skin color black or brown). These individuals experience structural and institutional racism [12], worse living conditions, with lower access to several basic social policies, such as basic sanitation, education and health [13]. This scenario is further worsened by the presence of lower income [13]. Although previous studies have sheds light on the impact of social inequalities on mental health, it is necessary to advance the analysis by investigati (...truncated)