This study supports previous studies in finding that Latino and African-American patients are less likely to obtain care for depression than are white patients. However, in this study, Latino and African-American patients reported that their primary care providers recommended depression treatments at rates similar to those of white patients. Unfortunately, ethnic minority patients were less likely to report that they actually took antidepressant medications or attended specialty care than were white patients. Overall, both Latino and African-American patients were much less likely to take antidepressant medications than were their white counterparts. Furthermore, Latinos were less likely than whites to obtain specialty mental health care.
These results offer hope that primary care practitioners are now recognizing and attempting to manage depression in their minority patients similarly to their white patients. Unfortunately, many of these patients fail to use antidepressant medications or obtain specialty care, suggesting that many Latino and African-American patients continue to lag behind whites in obtaining appropriate care for their depression.
Several factors could contribute to the lower use of antidepressant medications among the Latinos and African Americans. Evidence suggests that most primary care patients prefer counseling to medications, and this may be particularly true for Latinos and African Americans.19,20
African Americans are less likely to find antidepressant medication acceptable for treating depression, less likely to believe antidepressant medications are effective, and more likely to believe that antidepressant medications are addictive than whites.21
Although they may accept antidepressant prescriptions from their providers, they may be less likely to fill the prescription or take this medication if they feel uncomfortable with psychiatric medications. We would have liked to test this potential explanation for out findings; however, because acceptability of depression treatment and patient preferences were measured differently across the four studies in the QID sample, we were unable to adjust for patient preferences in our analyses.
One explanation for the lower rates of receiving care by minorities could be that differences in insurance benefits exist between white and minority participants. Data on insurance and prescription benefits were not uniformly collected across all four studies, and another limitation of this study is that we were unable to adjust for the potential impact of insurance and prescription benefits in our analyses. Nonetheless, minorities did not differ from whites in insurance coverage or prescription benefits in 3 of the 4 studies. Moreover, the vast majority of participants in the QID studies were insured; therefore, differences in benefit structure are not likely to be responsible for the observed ethnic differences in reports of care.
Recent work shows that ethnic minority patients have less collaborative relationships with their white providers than do white patients.9
Indeed, lower rates of participation in medical decision-making among ethnic minority patients might be an important contributor to health care and health disparities, since higher levels of patient involvement in care have been related to improved patient satisfaction, adherence, and health outcomes such as glycemic control, blood pressure control, and reduction of emotional distress.22,23
Perhaps patients who fail to take antidepressant medications could be encouraged to do so by primary care and specialty mental health providers through supportive patient education about depression care. Use of more patient-centered communication behaviors that elicit patient's explanatory models, concerns, and preferences regarding treatment may improve uptake of depression care, particularly for ethnic minorities.
Latinos are less likely to receive specialty mental health care than are African-American or white patients. This may be owing to difficulties obtaining care in Spanish or from providers that are sensitive to the cultural needs of these patients. Since both Latinos and African Americans are underrepresented among mental health professionals, ethnically matched mental health care is unlikely for many ethnic minorities.
Other factors may also contribute to the lower rates of care obtained by the minority patients. For example, Latinos may need family involvement for a particular family member to obtain mental health care. Because our medical system tends to suggest care only to the individual patient, failure to engage the family might lead to less likelihood of obtaining care. Furthermore, structural, financial, and other access barriers may also explain lower rates of care even among insured patients. Latino and African American families may have fewer resources, such as transportation, babysitting, or availability of out-of-pocket funds for obtaining care. These types of barriers may prohibit Latino and African-American patients from obtaining care for depression when it is needed.
Several limitations should be considered when evaluating these results. First, all of our data is self-report data from the patient perspective. Patient self-report of depression care during the previous 6 months may be affected by recall bias and lead to under-reporting actual use of care. However, there is no evidence that recall bias differs by ethnicity. Second, ethnic status is self-reported and limited to heterogeneous categories of African-American, Latino, and white patients. Further, no measure of acculturation or assimilation is available for minorities in this study. These factors could be associated with intraethnic variations in care or could partially explain the observed relations of patient ethnicity with treatment recommendations and actual receipt of treatment. Third, the study is cross-sectional, and therefore we were unable to examine the temporal relationships between provider treatment recommendations (e.g., prescription of antidepressant medication or referral to a mental health specialist) and patient receipt of care (taking recommended antidepressant medication or visiting mental health specialists). Fourth, clinical site variables (such as limits of time to see patients and availability of culturally appropriate personnel and educational materials) and patient social, cultural, and economic variables (such as patients’ trust in health professionals, explanatory models of illness, and perceptions of the financial burdens related to medications and counseling) were not uniformly measured across the four QID studies and could further explain racial and ethnic differences in treatment. Fifth, sampling and observation biases might be associated with this trial. The results are widely generalizable to the patients and providers associated with the diverse managed care organizations as represented in this study; however, this sample is primarily insured. Patients who declined to participate in the studies could have introduced bias. Of note, however, for these quality improvement studies, patients did not consent to randomized treatments but rather agreed to participate generally in the quality improvement studies. Similarly, physicians were aware that their practices were participating in a quality improvement for depression study. Although this may have heightened their awareness of depression, this should affect all patients so that our ethnic comparisons remain valid. Finally, our measures of depression treatment indicate only whether patients are taking antidepressant medications or attending a least one specialty visit and therefore do not represent quality of care measures.
The strengths of our study include the use of detailed clinical measures of depression symptomatology, measures of depression prescription, and treatment utilization. The studies’ inclusion of patients from a broad range of community-based primary care settings across the United States allows for generalization to diverse, insured populations in managed health care settings.
A major finding from this study is that African-American and Latino primary care patients are less likely to take antidepressant medication than are white patients, even when recommended to do so by their provider. These findings suggest that new approaches to treating depression in minority primary care patients are needed. Increasing the availability of effective psychotherapy options for minority patients may be helpful. For Latinos, this will require providing services in Spanish. For African Americans, it may require attention to cultural issues such as spirituality.23
In addition, interventions to improve the communication skills of primary care providers, particularly in the area of participatory decision-making, and to encourage ethnic minority patients to become more active participants in their care, expressing their concerns and preferences, are promising strategies to improve acceptance of treatment and depression outcomes for ethnic minority patients.