This study is one of the first to examine racial disparities in depression communication in a non-elderly primary care patient sample with depressive symptoms. We found that depression communication occurred in only one third of all visits, and African-American patients experienced less depression and rapport-building communication with their physicians than white patients. Racial differences in rapport-building and patient, but not physician, depression talk were attenuated after adjusting for patient and physician confounders. The amount of physician depression talk for African-American patients was one third of that for white patients.
Affect, which is conveyed primarily by voice tone, can be considered the unspoken subtext of the medical dialogue.40
With regard to global measures of affective tone, we found, similar to previous work, that physician and patient positive affect were lower in the visits of ethnic minority patients18,41
; however, in this smaller sample of patients with depressive symptoms, these findings were not statistically significant. Interestingly, coders also rated patient negative affect lower in the visits of African-American patients, lending credence to the hypothesis that African Americans provide fewer cues about their emotional status to physicians. As a result, their physicians may be less likely to engage in depression communication or to recognize emotional distress even when depression communication occurs.
Physician perceptions of patients’ physical health status may help to explain racial differences in their communication with patients and recognition of depressive symptoms. In this study, physicians rated a much higher percentage of African-American than white patients as having poor physical health. Physicians may fail to discuss depression with African-American patients because they are sicker when seeking care and present with more somatic attributions. Another potential explanation is that physicians have a higher threshold with regard to illness burden among African-American patients before depression is discussed. In the visits where depression communication did occur, 13 of the 15 African-American patients were considered to be in poor/fair health, while health status was less strongly related to depression discussion for white patients.
Overall, physicians rated only a slightly lower percentage of African-American than white patients as having enough emotional distress to be considered an illness. In visits where there was no depression communication, physicians identified about half of African-American and white patients as having significant emotional distress. However, even when depression communication did occur, physicians recognized only two thirds of African-Americans, but more than 90% of white patients, as having emotional distress. Intriguingly, engaging in depression communication (versus not doing so) increased the percentage of white patients whose symptoms were attributed to stress, but did not change physicians’ symptom attribution among African-American patients. When considered with the finding that recognition of emotional distress is not increased by having depression communication with African-American patients, this suggests that in addition to the quantity of depression communication, the nature of that communication may be different for African-American and white patients; our study did not address this possibility.
Other limitations of this study should be discussed. First, the study had a small sample size, and we may have failed to detect important differences in communication or physician perceptions by patient race because of limited statistical power. Second, generalizability of the physician and patient populations may be limited to similar practices and settings. Third, because this is a cross-sectional study of a single encounter for each patient, inferences regarding causal relationships between depression communication and physician perceptions cannot be made. Fourth, although we adjusted for mental and physical health status and found no racial difference in the severity of current depressive symptoms, unmeasured differences in presenting complaints or past treatment for depression may partially explain the observed racial differences in depression communication. Finally, we did not examine speaker initiation of depression communication. In previous studies where this issue was examined,20
investigators found that patients initiated depression communication just over half the time with no ethnic differences in initiation. Our finding of less depression talk by both patients and physicians in the visits of African-American patients suggests disparities in patient–physician depression communication are the result of mutual influence.
Our study has implications for future research and training of primary care physicians. More research is needed to improve understanding of how physician perceptions and patient attitudes influence depression communication, and how the nature of such communication impacts depression treatment and outcomes for patients. Additionally, communication skills training programs emphasizing patient-centered approaches have beneficial effects on clinician counseling behaviors and patient outcomes42–45
and should be tested as a mechanism to improve quality and reduce racial disparities in depression care. These programs should incorporate disease-specific content as well as strategies to improve clinicians’ rapport-building skills. Because untreated depression has a negative impact on self-management behaviors, morbidity, and mortality of patients with medical illnesses, this work is critically important to optimizing the quality and equity of both mental and physical health care in primary care settings.