Associations of Clinically Relevant Levels of Depressive Symptoms and Antidepressant Use With Mortality in African American Health.

BACKGROUND: The Institute of Medicine has highlighted unequal treatment for African American individuals in health care. We examined the association of underuse of antidepressants in African American individuals with increased mortality. METHODS: We conducted a longitudinal cohort study in Metropolitan St Louis, Missouri, in a population-based study of community-dwelling African American individuals, aged 52 to 68 years. Medication evaluations and clinically relevant levels of depressive symptoms (CRLDS) assessments occurred in 2000 and 2004. The analytic sample included 830 (of 853 total, 97%) participants with complete data. CRLDS was defined as ≥9 on the 11-item Center for Epidemiologic Studies Depression scale. Antidepressant use was determined by in-home medication recording and in-center coding. Participants were placed into 4 exposure categories: persistent CRLDS-no antidepressant (n = 69); intermittent CRLDS-no antidepressant (n = 123); antidepressant treatment (n = 110); and no CRLDS-no antidepressant (n = 528). Logistic regression with backwards elimination of the 9 identified potential confounders was used to examine associations of exposures with all-cause mortality over 6 years (2004-2010). Five sensitivity analyses investigated robustness of the primary findings. RESULTS: The antidepressant group was independently associated with reduced mortality compared with the persistent-no antidepressant group (odds ratio [OR] 0.19, 95% confidence interval [CI] 0.08-0.44). Sensitivity analyses showed no substantive differences from the primary model; one indicated that the persistent CRLDS-no antidepressant group experienced significantly increased mortality compared with the no CRLDS-no antidepressant group (OR 2.12, 95% CI 1.10-4.09), whereas the intermittent-no antidepressant group did not (OR 0.83, 95% CI 0.44-1.58). CONCLUSIONS: These results highlight that underuse of antidepressants in African American individuals is associated with increased mortality.

Neighborhood Conditions and Psychosocial Outcomes Among Middle-Aged African Americans.

OBJECTIVE: We examined associations between observed neighborhood conditions (good/adverse) and psychosocial outcomes (stress, depressive symptoms, resilience, and sense of control) among middle-aged and older African Americans. METHODS: The sample included 455 middle-aged and older African Americans examined in Wave 10 of the African American Health (AAH) study. Linear regression was adjusted for attrition, self-selection into neighborhoods, and potential confounders, and stratified by the duration at current address (<5 vs ≥5 years) because of its hypothesized role as an effect modifier. RESULTS: Among individuals who lived at their current address for ≥5 years, residing in neighborhoods with adverse versus good conditions was associated with significantly less stress (standardized ß = -0.18; P = .002) and depressive symptoms (standardized ß = -0.12; P = .048). Among those who lived at their current address for <5 years, residing in neighborhoods with adverse versus good conditions was not significantly associated with stress (standardized ß = 0.18; P = .305) or depressive symptoms (standardized ß = 0.36; P = .080). CONCLUSION: Neighborhood conditions appear to have significant, complex associations with psychosocial factors among middle-aged and older African Americans. This holds important policy implications, especially since adverse neighborhood conditions may still result in adverse physical health outcomes in individuals with >5 years at current residence despite being associated with better psychosocial outcomes.

Emergency Department Use Among Older Adults With Dementia.

Although persons with dementia are frequently hospitalized, relatively little is known about the health profile, patterns of health care use, and mortality rates for patients with dementia who access care in the emergency department (ED). We linked data from our hospital system with Medicare and Medicaid claims, Minimum Data Set, and Outcome and Assessment Information Set data to evaluate 175,652 ED visits made by 10,354 individuals with dementia and 15,020 individuals without dementia over 11 years. Survival rates after ED visits and associated charges were examined. Patients with dementia visited the ED more frequently, were hospitalized more often than patients without dementia, and had an increased odds of returning to the ED within 30 days of an index ED visit compared with persons who never had a dementia diagnosis (odds ratio, 2.29; P<0.001). Survival rates differed significantly between patients by dementia status (P<0.001). Mean Medicare payments for ED services were significantly higher among patients with dementia. These results show that older adults with dementia are frequent ED visitors who have greater comorbidity, incur higher charges, are admitted to hospitals at higher rates, return to EDs at higher rates, and have higher mortality after an ED visit than patients without dementia.

Improving the validity of activity of daily living dependency risk assessment.

OBJECTIVES: Efforts to prevent activity of daily living (ADL) dependency may be improved through models that assess older adults' dependency risk. We evaluated whether cognition and gait speed measures improve the predictive validity of interview-based models. METHOD: Participants were 8,095 self-respondents in the 2006 Health and Retirement Survey who were aged 65 years or over and independent in five ADLs. Incident ADL dependency was determined from the 2008 interview. Models were developed using random 2/3rd cohorts and validated in the remaining 1/3rd. RESULTS: Compared to a c-statistic of 0.79 in the best interview model, the model including cognitive measures had c-statistics of 0.82 and 0.80 while the best fitting gait speed model had c-statistics of 0.83 and 0.79 in the development and validation cohorts, respectively. CONCLUSION: Two relatively brief models, one that requires an in-person assessment and one that does not, had excellent validity for predicting incident ADL dependency but did not significantly improve the predictive validity of the best fitting interview-based models.

Effect of street connectivity on incidence of lower-body functional limitations among middle-aged African Americans.

PURPOSE: We hypothesize that lower street connectivity increases the risk of incident lower-body functional limitations (LBFLs) among urban African Americans aged 49-65 years. METHODS: This population-based cohort was interviewed in home visits. Five items measuring LBFL were obtained at baseline and after 3 years. Participants were considered to have LBFL if they reported difficulty on at least two of the five tasks. Census-tract street connectivity was measured as the ratio of the number of street intersections to the maximum possible number of intersections. RESULTS: Of 563 subjects with zero or one LBFL at baseline, 109 (19.4%) experienced two or more LBFLs at the 3-year follow-up. Adjusted logistic regression showed that persons who lived in census tracts with the lowest quartile of street connectivity were 3.45 times (95% confidence interval, 1.21-9.78) more likely to develop two or more LBFLs than those who lived in census tracts with the highest quartile of street connectivity independent of other important environmental factors. CONCLUSIONS: Areas with low street connectivity appear to be an independent contributor to the risk of incident LBFL in middle-aged African Americans.

Research priorities for high-quality geriatric emergency care: medication management, screening, and prevention and functional assessment.

BACKGROUND: Geriatric adults represent an increasing proportion of emergency department (ED) users and can be particularly vulnerable to acute illnesses. Health care providers have recently begun to focus on the development of quality indicators (QIs) to define a minimal standard of care. OBJECTIVES: The original objective of this project was to develop additional ED-specific QIs for older patients within the domains of medication management, screening and prevention, and functional assessment, but the quantity and quality of evidence were insufficient to justify unequivocal minimal standards of care for these three domains. Accordingly, the authors modified the project objectives to identify key research opportunities within these three domains that can be used to develop QIs in the future. METHODS: Each domain was assigned one or two content experts who created potential QIs based on a systematic review of the literature, supplemented by expert opinion. Candidate QIs were then reviewed by four groups: the Society for Academic Emergency Medicine (SAEM) Geriatric Task Force, the SAEM Geriatric Interest Group, and audiences at the 2008 SAEM Annual Meeting and the 2009 American Geriatrics Society Annual Meeting, using anonymous audience response system technology as well as verbal and written feedback. RESULTS: High-quality evidence based on patient-oriented outcomes was insufficient or nonexistent for all three domains. The participatory audiences did not reach a consensus on any of the proposed QIs. Key research questions for medication management (three), screening and prevention (two), and functional assessment (three) are presented based on proposed QIs that the majority of participants accepted. CONCLUSIONS: In assessing a minimal standard of care by which to systematically derive geriatric QIs for medication management, screening and prevention, and functional assessment, compelling clinical research evidence is lacking. Patient-oriented research questions that are essential to justify and characterize future QIs within these domains are described.

Adverse housing and neighborhood conditions and inflammatory markers among middle-aged African Americans.

Adverse housing and neighborhood conditions are independently associated with an increased risk of various diseases and conditions. One possible explanation relates to systemic inflammation, which is associated with these adverse health outcomes. The authors investigated the association between housing and neighborhood conditions with inflammatory markers using data about 352 persons aged 49-65 years from the African American Health study. Participants were identified by a multistage random selection process in 2000 to 2001(response rate, 76%). Blood was analyzed for soluble cytokine receptors (interleukin-6, tumor necrosis factor alpha), C-reactive protein, and adiponectin. Neighborhood and housing characteristics consisted of five observed block face conditions (external appearance of the block on which the subject lived), four perceived neighborhood conditions, four observed housing conditions (home assessment by the interviewers rating the interior and exterior of the subject's building), and census-tract level poverty rate from the 2000 census. Differences in some inflammatory markers were found by age, gender, chronic conditions, and body mass index (all Bonferroni-adjusted p < 0.0034). There was no association between any of the housing/neighborhood conditions and the pro-inflammatory markers and potential associations between some housing/neighborhood conditions and adiponectin (p < 0.05, Bonferroni-adjusted p > 0.0034). Inflammation does not appear to be a mediator of the association between poor housing/neighborhood conditions and adverse health outcomes in middle-aged African Americans.

Predictors of change in grip strength over 3 years in the African American health project.

OBJECTIVE: To examine factors associated with change in grip strength. METHOD: Grip strength was measured at baseline and 3 years later. Change was divided into "decreased >/=5 kg," "increased >/=5 kg," and "no change" and analyzed using multinomial multivariable logistic regression. RESULTS: Decline in grip strength was more likely for men, those reporting having cardiovascular disease, and those with instrumental activities of daily living, lower body functional limitations, high diastolic blood pressure, higher physical activity, and greater body mass. Decline was less likely among those ever having Medicaid, those with basic activities of daily living disabilities, and those unable to see a doctor in past year due to cost. Gain in grip strength was more likely for men and those with instrumental activities of daily living disabilities, lower body functional limitations, high diastolic blood pressure, and higher physical activity; it was less likely for older participants. DISCUSSION: Results can be used to design interventions to improve strength outcomes.

Preparing for an aging population and improving chronic disease management.

New models of health care delivery are inevitable. There is likely to be increasing emphasis on patient self-monitoring, health care delivery at patient homes, interdisciplinary treatment plans, a greater percentage of medical care delivered by non-physician health professionals, targeted health educational materials, and greater involvement and training of informal caregivers. The Information Technologies (IT) infrastructure of health systems will need to adapt. We have begun sorting out the implications of this future within a County public hospital system: defining the desirable features, relevant technologies, necessary modifications to the network, and additional data elements to be captured. We seek to build an infrastructure that will support new patient-focused technologies designed to more efficiently and effectively support older individuals. We hypothesize utility to further exploring the impact that new health care delivery models will have on health systems' IT infrastructures.

Antecedents of global decline in health-related quality of life among middle-aged African Americans.

OBJECTIVE: We examined global declines in health-related quality of life (HRQoL) for a period of 3 years among the 998 participants in the African American Health (AAH) project. METHODS: The AAH is a population-based sample from two areas of metropolitan St. Louis. Global declines were defined as clinically important differences (CIDs) on four or more of the eight Short Form 36-Item scales. Individual CIDs were defined as drops of 0.5 SD or more from the baseline score. Multivariable logistic regression was used to identify antecedents of global decline. RESULTS: Fourteen percent (n = 117) of the 846 AAH subjects in the analysis demonstrated global declines in HRQoL. Five statistically significant risk factors were identified, including sampling strata (inner-city vs. suburban residence; adjusted odds ratio [AOR] = 2.06), cancer (AOR = 3.56), chronic obstructive pulmonary disease (AOR = 2.19), clinically relevant levels of depressive symptoms (AOR = 1.96), and incident (postbaseline) health conditions (1 [AOR = 1.71] and > or =2 [AOR = 3.09] vs. none). CONCLUSION: Although these risk factors are for the most part nonmalleable, they can serve as markers of impending global HRQoL declines among late-middle-aged African Americans.

Rating neighborhoods for older adult health: results from the African American Health study.

BACKGROUND: Social theories suggest that neighborhood quality affects health. Observer ratings of neighborhoods should be subjected to psychometric tests. METHODS: African American Health (AAH) study subjects were selected from two diverse St. Louis metropolitan catchment areas. Interviewers rated streets and block faces for 816 households. Items and a summary scale were compared across catchment areas and to the resident respondents' global neighborhood assessments. RESULTS: Individual items and the scale were strongly associated with both the catchment area and respondent assessments. Ratings based on both block faces did not improve those based on a single block face. Substantial interviewer effects were observed despite strong discriminant and concurrent validity. CONCLUSION: Observer ratings show promise in understanding the effect of neighborhood on health outcomes. The AAH Neighborhood Assessment Scale and other rating systems should be tested further in diverse settings.

Neighbourhood environment and the incidence of depressive symptoms among middle-aged African Americans.

AIM: To investigate the association between attributes of subject location and incidence of clinically relevant levels of depressive symptoms (CRLDS), and to investigate whether an association remained after adjusting for individual-level factors using data from the population-based African American Health Study. METHODS: An 11-item depression scale (Center for Epidemiologic Studies Depression scale) was obtained at baseline and 3 years later through in-home evaluations. Census tract and block group deprivation indices were obtained from the 2000 census. The external appearance of the block where the subject lived was rated during sample enumeration, and the interior and exterior of the subject's dwelling were observed during the initial in-home interview. RESULTS: Of 998 subjects at baseline, 21.1% had CRLDS. Although 12.7% of the 672 people without CRLDS at baseline developed them by the 3-year follow-up, univariate and propensity-adjusted analyses revealed no association between the subject's location and the incidence of CRLDS. Sensitivity analyses confirmed the robustness of the findings. CONCLUSION: Despite other studies showing independent effects of neighbourhood characteristics on the prevalence of CRLDS, attributes of subject location are not independent contributors to the incidence of CRLDS in middle-aged urban African Americans.

Educational disparities in the prevalence and consequence of physical vulnerability.

OBJECTIVES: The purpose of this study was to estimate educational differences in the prevalence and mortality consequence of physical vulnerability among older adults in the United States. METHODS: Data came from the 1998 and 2000 waves of the Health and Retirement Study, a nationally representative cross-sectional and prospective cohort study of community-based adults aged 65 and older. We created a physical vulnerability score from age, gender, and self-reported disability measures and measured socioeconomic status via educational attainment. Mortality data came from the National Death Index. RESULTS: In the 1998 cohort, high physical vulnerability was more than 3 times more prevalent in individuals with less than 12 years of education compared to those with 16 or more years of education. Although less educated older adults had a higher probability of death overall, evidence of educational differences in the mortality consequence of high physical vulnerability was limited. In 2000, 2.16 million older adults had high physical vulnerability, and more than one half (53%) of these adults had less than 12 years of education. DISCUSSION: In persons 65 years of age or older, educational differences are more apparent in the prevalence of physical vulnerability than in the mortality consequence of that vulnerability.

Effect of subclinical status in functional limitation and disability on adverse health outcomes 3 years later.

BACKGROUND: This article examines the effect of self-reported, baseline subclinical status (i.e., independent but adaptive performance) for functional limitation and disability on adverse health outcomes. METHODS: Nine hundred ninety-eight African-American men and women aged 49-65 years received in-home evaluations at baseline, and 853 were re-evaluated 3 years later. Baseline subclinical status was ascertained for five lower body tasks and seven activities of daily living (ADLs)/instrumental ADLs (IADLs). Outcomes included difficulty with lower body limitations, ADLs/IADLs, physical performance, physician visits, hospitalization, nursing home placement, and mortality. RESULTS: The baseline proportion of subclinical status evidence for the five lower body items was 0.33 (standard deviation [SD] = 0.20), and for the seven ADLs/IADLs was 0.20 (SD = 0.30). Significant independent effects of subclinical status for lower body limitations were observed on physician visits and hospitalization. Significant independent effects of subclinical status for ADLs/IADLs were observed on ADLs/IADLs and physician visits. CONCLUSIONS: Subclinical status for functional limitation and disability independently predicts several subsequent adverse health outcomes, although the effects of the latter (ADLs/IADLs) are stronger. Interventions to reduce frailty should focus on self-reported subclinical status as an early warning system.

Reliability and validity of observer ratings of neighborhoods.

OBJECTIVES: The objectives were to examine the validity and reliability of a five-item neighborhood measurement scale. METHODS: Respondents were enrolled from two catchment areas: a poor inner city and a heterogeneous suburban area. Items combine for a total score of 5 (best) to 20 (worst). The authors compared scales across catchment areas and respondent ratings and assessed interviewer effects and retest reliability. RESULTS: Suburban neighborhood scale scores were 3 points lower (higher socioeconomic status, SES) than the inner-city scores. There was a strong relationship between scores and participants' neighborhood ratings. The retest correlation was substantial (.81), but only two of five items achieved kappas above .75. In regression models, interviewer experience and residence and individual interviewers contributed to different ratings, although there was still a marked difference between catchment areas. DISCUSSION: Observer ratings of neighborhoods show promise as a measure of neighborhood SES, despite problems with interviewer effects. Future work should improve objective criteria for ratings.

Neighborhood conditions and risk of incident lower-body functional limitations among middle-aged African Americans.

The authors investigated the association between observed neighborhood conditions and lower-body functional limitations (LBFLs) using data from 563 subjects of the African-American Health Study. This population-based cohort received in-home evaluations. Five items involving LBFL were obtained at baseline (2000-2001) and 3 years later. Subjects were considered to have LBFL if they reported difficulty on at least two of the five tasks. The external appearance of the block the respondent lived on was rated during sample enumeration by use of five items (rated excellent, good, fair, or poor). Of 563 subjects with 0-1 LBFL at baseline, 15% and 14% lived in neighborhoods with 4-5 and 2-3 fair/poor conditions, respectively. Logistic regression adjusting for propensity scores showed that persons who lived in neighborhoods with 4-5 versus 0-1 fair/poor condition were 3.07 times (95% confidence interval: 1.58, 5.94) more likely to develop two or more LBFLs. The odds ratio was 2.24 (95% confidence interval: 1.07, 4.70) when living in neighborhoods with 2-3 conditions versus 0-1 fair/poor condition. Odds ratios for individual neighborhood characteristics varied from 3.45 (fair/poor street conditions) to 2.01 (fair/poor noise level). Sensitivity analyses showed the robustness of the findings. Poor neighborhood conditions appear to be an independent contributor to the risk of incident LBFLs in middle-aged African Americans.

The future (history) of socioeconomic measurement and implications for improving health outcomes among African Americans.

Socioeconomic status (SES) has powerful and complex impacts on health, and understanding the relationship between SES and health is essential for long-term improvements in the health of populations. In addition, in the United States, the impact of SES on health is inextricably intertwined with racial and ethnicity status and the historical development and maintenance of health disparities. Most of the literature documenting this relationship has focused on individual-level socioeconomic factors. There are sound theoretical reasons and some empirical support to suggest that socioeconomic resources at both individual and neighborhood levels have strong influences on health outcomes such as disease, disability, and mortality. However, these relationships have been inadequately examined to date. In this article, the term "ecological SES" will be used to denote SES at geographic group levels. As the United States attempts to achieve the goals of the Department of Health and Human Services' Healthy People 2010 program, understanding ecological SES and its impacts on health will be crucial. We review the theory, some of the empirical evidence, and likely future for the measurement and use of a broader approach to SES and offer a specific research paradigm for examining these issues. We focus in particular on one racial-ethnic group that experiences health disparity, that is, African Americans. We use our ongoing project investigating physical frailty in urban African Americans to illustrate the importance of a multilevel approach to understanding the impacts of socioeconomic resources on health and the potential implications for efforts to prevent or reverse frailty.

Inner city, middle-aged African Americans have excess frank and subclinical disability.

BACKGROUND: Healthy People 2010 seeks to decrease or eliminate the health disparities experienced by disadvantaged minority groups. METHODS: African American Health (AAH) is a population-based panel study of community-dwelling African Americans born between 1936 and 1950 from two strata. The first encompasses a poor, inner city area, and the second involves a suburban population with higher socioeconomic status. The authors recruited 998 participants (76% recruitment). Frank disability was assessed for 25 tasks and defined as inability or difficulty performing that task. Subclinical disability was assessed for 12 tasks and defined as no difficulty but a change in either manner or frequency of task performance. Frank disability prevalences were compared with national data for community-dwelling non-Hispanic white persons (NHW) and African American persons in the same age range. RESULTS: Compared with the suburban sample, the inner city group had a higher prevalence of frank disability for all 25 tasks (p<.05 for 16) and subclinical disability for 11 of the 12 tasks (p<.05 for 5). Both strata had more frank disability compared with the national NHW population. The inner city area had higher frank disability proportions than did the national African American sample, whereas the suburban group had similar disability levels. CONCLUSIONS: The AAH inner city group experiences more frank disability than other populations of African Americans and NHWs. The increased prevalence of subclinical disability in the inner city group compared with the suburban group suggests that the disparity in frank disability will continue. These findings indicate that African Americans living in poor inner city areas in particular need intensive and targeted clinical and public health efforts.

Further evidence for the importance of subclinical functional limitation and subclinical disability assessment in gerontology and geriatrics.

OBJECTIVE: The objectives of this work were to determine the prevalence of self-reported subclinical status for functional limitation and disability at baseline and assess their independent effects on the onset of functional limitation and disability 1-2 years later. METHODS: Nine hundred ninety-eight African American men and women 49-65 years old in St. Louis, MO, received comprehensive in-home evaluations at baseline and two annual telephone follow-ups. Outcome measures included walking a half-mile, climbing steps, stooping-crouching-kneeling, lifting or carrying 10 lbs., and doing heavy housework. RESULT: The baseline prevalence of subclinical status was 26.4% for walking a half-mile, 26.8% for climbing steps, 39.0% for stooping-crouching-kneeling, 29.1% for lifting or carrying 10 lbs., and 22.7% for doing heavy housework. The adjusted odds ratios for the task-specific subclinical status measure at baseline on developing difficulty 1-2 years later were 1.68 (p < .05) for walking a half-mile, 4.46 (p < .001) for climbing steps, 2.48 (p < .001) for stooping-crouching-kneeling, 2.51 (p < .001) for lifting or carrying 10 lbs., and 2.22 (p < .001) for doing heavy housework. Performance tests (tandem stand, chair stands, and preferred gait speed) did not have consistent independent effects on the onset of functional limitation or disability. CONCLUSION: The subclinical status measures were the main predictors of the onset of difficulty in all tasks and functions 1-2 years later. Interventions to reduce frailty should focus on self-reported subclinical status as an early warning system.

Clinically relevant levels of depressive symptoms in community-dwelling middle-aged African Americans.

OBJECTIVES: To identify the prevalence of and potentially modifiable risk factors for clinically relevant levels of depressive symptoms in a population-based sample of community-dwelling African Americans and the prevalence of treatment by prescription and alternative medications. DESIGN: Cross-sectional survey, 2000-01. SETTING: Community-based. PARTICIPANTS: Nine hundred ninety-eight noninstitutionalized African Americans in St. Louis, Missouri, born between 1936 and 1950. MEASUREMENTS: Depressive symptoms were measured using the 11-item Center for Epidemiologic Studies Depression scale (CES-D). Clinically relevant levels of depressive symptoms were defined as nine or more (equivalent to >/=16 on the 20-item CES-D). A comprehensive set of risk factors was considered that included three demographic variables, eight socioeconomic-access measures, four environmental factors, seven measures of functional status, 15 biomedical markers, one service utilization indicator, and three psychosocial measures. All analyses were weighted to the represented population. Treatment with an antidepressant was determined by examining subjects' medications compiled in their homes. RESULTS: Two hundred ten subjects (21.1%) had clinically relevant levels of depressive symptoms. Several multivariate logistic regression approaches were used for model building, which identified a consistent set of nine predictive factors: female sex (odds ratio adjusted (AOR) for all factors in the final model=1.52; 95% confidence interval (CI)=1.01-2.27), lower objective income (AOR=1.62, 95% CI=1.08-2.43), perceived income inadequacy (AOR=2.33, 95% CI=1.49-3.65), lower assessment of home environment (AOR=1.07 per scale point, 95% CI=1.01-1.12), limitations in visual acuity (AOR=1.12 per scale point, 95% CI=1.04-1.21), being severely underweight (AOR=2.52, 95% CI=1.02-6.20), being obese (AOR=1.72, 95% CI=1.16-2.54), being hospitalized in the previous year (AOR=2.25, 95% CI=1.45-3.49), and lower social support (AOR=1.20 per scale point, 95% CI=1.16-1.26). Of these, social support was the most important (adjusted standardized odds ratio =2.41). Forty-one (19.5%) of the subjects with clinically relevant levels of depressive symptoms were taking prescription antidepressants. CONCLUSION: The prevalence of clinically relevant levels of depressive symptoms in middle-aged African Americans was greater than that for the general U.S. population. Community-based health programs that screen for depression and refer individuals to clinical care sites with appropriately designed systems of care for depression management should be developed. For optimal effect, these programs should concentrate their efforts in socioeconomically disadvantaged areas and address socioeconomic factors such as income inadequacy and social support in addition to the biomedical risk factors. Given the pervasive adverse effects of depression, such interventions have the potential for significantly enhancing the health of African Americans in their later years and reducing current health disparities.