Discussion
Barriers in evaluation
Research on depression in African Americans can be analyzed in terms of attributes of the provider, patient, and practice setting.
Provider attributes. The race of the physician has been linked to the diagnosis of depression in African-American patients, but studies of this factor have yielded conflicting results. McKinlay and colleagues used videotaped cases of depressed patients presented to 128 physicians to examine whether diagnosis was affected by physician characteristics (age, gender race, and medical specialty), patient characteristics (age, gender, race, and socioeconomic status), or their combination.37 They found that physician characteristics affected the diagnosis of depression, but that patient attributes did not. In particular, white primary care physicians were twice as likely as African American physicians to diagnose depression. Since approximately 1 in 5 African American patients seeks care from a physician of their own race,47 such differences may influence the overall rate of recognition in primary care. However, data from the Medical Outcome Study, which included demographic characteristics on 349 primary care physicians, did not find that the race of the physician influenced the detection of depression.3
In addition to physician demographic factors, physician communication style may affect ability to diagnose depression. Appropriate diagnosis and treatment of depression depends to a great extent on verbal communications between patient and provider about the nature, extent, severity, and consequences of symptoms. Problems with communication may lead to misunderstandings, misdiagnosis, inappropriate treatments, and premature termination of treatment. An analysis of patient-physician encounters indicates that physicians may be more likely to minimize emotional symptoms of African American than of whites.42 Relative to whites, African Americans are more likely to rate their visits with white physicians as less participatory.
This difference is overcome when African Americans see physicians of their own race.23 In a population-based study among largely low-income African American women, primary care physicians who were rated as showing more respect by the participants were more likely to inquire about depressive symptoms during a clinical visit.40 Thus, despite the fact that African American patients rate their encounters more satisfying and are more likely to disclose their problems to African American physicians, white physicians appear to diagnose depression more commonly in their African American patients. Clearly, more work is needed to clarify this seeming contradiction.
Patient attributes. During the primary care encounter, African Americans are as likely as whites to discuss mental health problems.34 However, African Americans may be more likely to exhibit somatic and neurovegetative symptoms of depression than mood or cognitive symptoms,33,36 which may complicate detection and diagnosis.
A recent national survey suggests that depression in African Americans may be commonly masked by self medication and somatic symptoms and so may pass undetected in primary care.48 In a randomized clinical trial of depression treatment in primary care, depressed African American subjects were more likely than white subjects to have symptoms of poor physical health and pain and to have somatization.29 However, another study found few differences between whites and African Americans in symptom presentation of depression when comorbid disorders and sociodemographic factors were controlled.46
Do primarily somatic presentations of depression reduce physicians’ ability to accurately diagnose major depression in racial and ethnic minorities? This question has not been studied, though coexisting medical problems in primary care populations have been found to impede the diagnosis of depression,49 presumably by competing for the physician’s attention.3,50 In a variety of medical contexts, known medical disorders are associated with under-treatment of unrelated disorders.51
Practice-setting attributes. No studies have examined whether specific practice setting factors, such as insurance coverage, are related to the low detection rate of major depression. Among low-income women of multiethnic backgrounds attending primary care clinics, Van Hook found that perceived separation of primary care services and specialty mental health care was a self-reported barrier to seeking help for depression.44
The Surgeon General’s report documents the overall poor access to general medical services faced by African Americans. They are more likely to receive health care in outpatient hospital and emergency departments, and their mental health services are also characterized by high rates of emergency care. As a result, they are less likely to receive the continuity of treatment provided in primary care, which may allow better detection of depression.15
Barriers to effective management
Research on the potential causes of disparities in treatment for African American patients in primary care has examined a variety of provider, patient, and practice-setting factors.
Provider attributes. Physician communication style may not only influence diagnosis but also a decision to treat. In a study that analyzed audiotaped communication between patients and primary care providers during clinic visits, the tendency of physicians to minimize emotional expression by African Americans, relative to whites, led to lower prescribing of antidepressant medication among African Americans.42 Further research is needed to understand why such communication styles exist between primary care providers and African American patients.