As expected, primary care physicians responded to the severity of depression symptoms in their patients. Physicians were more likely to detect depression among patients with more serious DIS diagnoses, such as major depression concurrent with dysthymia, than among patients with milder symptoms. This can be viewed as reassuring evidence that more severe symptoms trigger recognition of mental health problems in primary care settings. A disturbing finding, however, was that patient race/ethnicity and gender influenced physician recognition of mental health problems.
Several studies have demonstrated that race and ethnicity affect receipt of a variety of medical services,33–36
including mental health specialty care.20–23
Different causes for these mental healthcare disparities have been suggested, including patient and family feelings of stigma related to mental health disorders37
and low patient education about depression and its symptoms. However, neither the rates at which patients report discussing mental health problems with primary care providers, nor their desire for mental health treatment varies by race.38,39
Surprisingly few studies have focused on provider behaviors, such as the tendency to detect depression, as potential barriers to mental health care for minority patients. We found that primary care physicians were less likely to detect mental health problems among African-American and Hispanic patients than among whites. Poor primary care provider detection of depression is a major barrier to appropriate care for these patients because they are even more unlikely than nonminority populations to access care for this illness from any other source40
Measurement bias could be responsible for our results if the MOS measurement instruments were more likely to classify African Americans or Hispanics than whites as having a mental health problem, but this is not the case. Several of the items in the MOS brief screening instrument have been demonstrated to be not more, but less sensitive to depressive symptomatology among African-American men compared with other race-gender groups.41
Adding physician characteristics to our multivariate models reduced the significance of ethnicity in predicting detection, though it remained significant at conventional levels. When we investigated this decrement, we found that a contributing factor to the lower detection rate for minority patients was their tendency to receive care from physicians with lower proclivities for depression counseling. The factors underlying this difference should be further studied, especially in light of other recent evidence suggesting that the degree to which patients view their physicians' style as receptive to patient involvement in treatment decision making varies by patient race, with African Americans less likely to perceive a participatory style.42
Further research will be needed to increase our understanding of how race and ethnicity influence the manner in which patients express and physicians interpret symptoms reflecting mental health problems and how these elements of patient-physician communication are translated into clinical decisions.
Our findings on gender extend those of a previous study of detection among men and women in the MOS that found physicians were more likely to report being aware of depression among women than among men.18
Our study similarly examined whether physicians' reported awareness of depression, but also assessed whether physicians reported a mental health problem as the reason for the office visit and whether they counseled the patient for a mental health problem or referred the patient to a mental health specialist for any reason. Using this more liberal definition of detection, we also found that physicians were more likely to be aware of or act on mental health issues for women than for men.
Physicians detected nearly 60% of patients in this study with major depression, but detected fewer of the patients with dysthymia, subthreshold depression, or symptoms of depression that did not meet a DIS diagnosis. These absolute rates of detection are consistent with many other studies that indicate the need for better depression recognition. The presence of a common medical illness (hypertension or diabetes) raised detection rates significantly. One explanation for this relationship is that patients with medical conditions are seen more frequently and thus their physicians can more accurately interpret their symptoms of mental distress. Our models are weighted for the length of time since the last visit; this may not completely account for differences in visit frequency. Alternatively, medical physicians may feel more responsible for patients with medical conditions, or these patients may feel more comfortable presenting their problems to their physicians. More research is needed to determine why awareness of psychological distress may be better among patients with coexistent medical problems, and not worse, as a competing demands model would predict.
Certain limitations to this study should be recognized. Our assessment of detection is cross-sectional and may not reflect physician actions before or after the study visit. In addition, physicians may have recognized psychological distress at the screening visit in ways not captured by our measure of detection. For example, physicians may have prescribed antidepressants or may have recognized a mental health problem as a secondary, rather than a primary reason for a visit. We chose not to use antidepressant prescriptions as an indicator of detection because they are frequently prescribed for conditions other than mental health disorders, such as pain. Although we use comprehensive measures of health and functional status in the screening sample model, and DSM-III diagnoses in the DIS sample, differences in detection among patient subgroups may be related to unmeasured differences in severity of psychological distress. Furthermore, we did not have diagnostic information about mental health problems other than depressive syndromes (e.g., substance abuse). The association between detection of mental health problems and the concurrent presence of hypertension or diabetes may be even stronger than we found, because some patients without those conditions had other chronic diseases that may enhance detection.
We conclude that patients' race, gender, and coexisting medical conditions affect physician awareness of mental health problems. More severe psychological distress increases the likelihood of detection, but detection also varies substantially in relation to patient ethnicity/race and gender. Strategies to improve detection of mental health problems in African Americans, Hispanics, and men should be explored and evaluated. Future research should identify the determinants, including those related to provider characteristics, of low rates of detection of mental health problems in these populations, and should evaluate interventions to eliminate racial, ethnic, and gender disparities in depression care.