Sociodemographic inequality
There are several possible explanations for the social inequalities in the treatment of depression in general practice. Patients' health literacy and preferences may be associated with education level and age, and this may influence GPs' treatment decisions. Health literacy refers to the ability to access, understand, evaluate and apply health information, and levels of health literacy tend to be higher among younger and more highly educated patients than older and less educated groups (9). GPs' assumptions about a patient's health literacy, based on implicit biases and stereotypes, can also influence their treatment decisions (10, 11). Highly educated women may be more aware of the limited effects and potential adverse effects of antidepressants and may therefore prefer talking therapy over pharmacological treatment. They may also feel more confident in advocating for their own health and expressing their treatment preferences. As there is no evidence that the severity of depression varies by education level, it is possible that highly educated women are under-treated with antidepressants when these are indicated, while women with a lower level of education may be over-treated.
Regardless of age and sex, patients with depression prefer psychological treatment over antidepressants (12). Engagement and a sense of ownership of treatment increase the likelihood of a positive outcome (13) and should therefore be important considerations when GPs assess treatment options.
Age and education-related differences in the treatment of depression suggest systematic inequality, which can exacerbate health disparities and affect vulnerable groups, particularly older adults and those with a low level of education
If doctors assume that older or less educated patients have a reduced capacity to engage in or benefit from talking therapy, they may favour pharmacological treatment without investigating whether this assumption is justified. Indeed, talking therapy is discussed less often with older patients than with younger ones (14). However, the use of antidepressants in older adults is associated with a higher risk of adverse effects and drug interactions than in younger patients, particularly in cases of multimorbidity and polypharmacy (15). This evidence suggests that antidepressants should be used less for older patients than middle-aged and younger ones. International literature refers to age discrimination, or ageism, as a potential explanation for negative attitudes and differential treatment of older people (16).