Patient views regarding the importance of various aspects of depression care were similar for African Americans and whites, except for the importance of spirituality. African-American patients in this study were more likely than whites to rate spirituality as an extremely important aspect of care for depression. Research linking religious involvement with psychological well-being among African Americans indicates that prayer is an important means of coping with serious personal problems.17
Of note, the aspects of spirituality rated as extremely important were of a private and intrinsic nature, reflecting active coping with depressive symptoms such as feelings of guilt and hopelessness. In contrast, items related to public religiosity, such as church attendance and social support from church members, were not rated among the top 30 items.
Limitations of this study include its small sample size from 1 geographic area, the nonrandom selection of patients, and the heterogeneity of depressive diagnoses and symptoms. The sample was also younger, more educated, and had a higher prevalence of previous mental health treatment than many other primary care samples. Additionally, the whites in our sample were more educated, and the African Americans, less educated, than national averages. Although we adjusted for educational status in our multivariate analyses, there remains the potential for residual confounding of the relationship between race and importance ratings because of socioeconomic status and other unmeasured characteristics. Nonetheless, the study contributes to the literature because little work has been done previously to compare African-American and white primary care patients' priorities for treatment of depression.
Our focus on spirituality was guided by our previous qualitative research as well as by other literature regarding the importance of spirituality to African Americans. Because of the strength of the association and its consistency across several items in the same domain, it is unlikely that the findings related to spirituality and race occurred by chance. Because we performed 39 individual regression analyses, several other significant findings might have resulted by chance alone.
Research indicates that patients want their physicians to address issues of faith and spirituality in the course of their treatment, and that patients with strong spiritual and religious tendencies are receptive to physicians referring them to pastoral counselors or praying with them.18
However, primary care physicians cite lack of time and inadequate training as the most important barriers to discussing spirituality with patients.19
Not much is known about how, when, and with whom patients would like to discuss their spiritual needs in the context of medical care. Some authors suggest that physicians routinely use a spiritual needs assessment with patients—asking patients whether or not they consider themselves to be religious or spiritual, how important faith is in the patient's daily life, whether or not the patient belongs to a community of faith, and how the patient would like the physician to address these issues in their health care.20
Physicians might also try to ascertain whether patients' religious views and coping styles are healthy and facilitate adjustment or whether these views are dysfunctional, contribute to psychopathology, or impede patients' ability to benefit from medical care. If physicians feel their patients require more spiritual care than they are able to provide, referrals could be made to pastoral counselors with patients' consent.
This exploratory study suggests that acknowledgment of spirituality within the context of care of depression may be particularly important for African Americans. Future research should use larger samples of primary care patients to compare attitudes toward the inclusion of spirituality in depression care between African Americans and whites and to identify the range of appropriate ways for health professionals to address the spiritual needs of their patients who place a high value on spirituality.