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Black Americans are more likely to obtain mental health care from primary care than from a mental health specialist. Our objective was to investigate the association of ethnicity with the identification and active management of depression among older patients.
Cross-sectional survey 355 older adults with and without significant depressive symptoms. At the index visit, doctor's ratings of depression and reports of active management were obtained on 341 of the 355 patients who completed in-home interviews.
Older black patients were less likely to be identified as depressed than were older whites (unadjusted odds ratio (OR) = 0.40, 95% confidence interval (CI) [0.25, 0.63]) and less likely to be actively managed for depression in the 6 months prior to interview (unadjusted OR = 0.63, 95% CI [0.19, 2.16]). In multivariate models that controlled for potentially influential characteristics such as patient age, gender, marital status, level of education, functional status, physical health, severity of depressive symptoms, severity of anxiety symptoms, attitudes about depression, number of office visits in the last 6 months, and the doctor’s rating of how well they knew the patient, the associations of identification (OR = 0.25, 95% CI [0.17, 0.39]) and management (OR = 0.57, 95% CI [0.19, 1.77]) with patient ethnicity remained substantially unchanged.
Our study calls attention to the role ethnicity may play in the identification and active management of depression among older primary care patients.
The Surgeon General renewed attention to the problem of unrecognized and untreated depression among older adults,1 stating that the primary care setting may provide the only opportunity in which serious depression and other mental conditions that affect minority elderly can be addressed.2 Primary health care is pivotal for the initial identification and management of depression among older persons.3 African-American patients are more likely than white patients to obtain mental health care from a primary care provider.4–7 The increase in antidepressant use among older adults has occurred mostly among white patients.8 Despite the increase in antidepressant use among older adults, once in care, black patients appear to be less likely than white patients to be appropriately diagnosed9 or to receive care thought to be effective for depression.5, 10 Black patients have been reported to be less likely than whites to adhere to depression treatment once initiated,11 even though no difference in treatment response according to ethnicity among patients who accept and sustain treatment has been identified.12 None of the cited studies focused on older primary care patients.
At the outset, we acknowledge that terms of race and ethnic origin are coarse markers of complex social and behavioral patterns. Ethnicity refers to a common heritage shared by a particular group.13 Culture is broadly defined as a common heritage or set of beliefs, norms, and values.2 We recognize that designations of ethnic status imply a homogeneity within groups which is a simplification.14, 15 Consistent with current publications of the National Institutes of Health,16 we use the term “black” to include individuals of African, African-American, and African-Caribbean descent and “white” to include individuals of European descent. Any differences we observe across ethnic groups are likely to represent measured and unmeasured differences in social class, exposures, health beliefs and practices, and other characteristics.17
The goal of this investigation was to examine the characteristics of older patients whom primary care physicians rate as depressed, with a focus on the ethnicity of the patient. We hypothesized that black patients might have a different experience regarding depression identification and management than white patients in primary care practice. Our conceptual framework was a simplified version of the model suggested by Cooper and colleagues18 (Figure 1). In this model, attitudes and familiarity with the practice mediate the relationship between patient ethnicity and identification and active management by primary care physicians. In the work of Cooper and coworkers, attitudes to depression and its treatment did not completely explain the relationship between patient ethnicity and acceptance of treatment for depression.
The overarching goal of the Spectrum Study was to characterize how depression presents in older primary care patients. The design of the Spectrum Study was a cross-sectional survey of patients and doctors. In all, 47 physicians (28 family physicians and 19 internists) from 13 practices contributed patients who participated in the Spectrum study.19, 20 Practices were selected to achieve a substantial representation of black patients. Experienced agency interviewers worked with office staff at each practice to identify all patients aged 65 years and older. All such patients who came to a participating office were approached and asked to join in a study of health and aging. The study protocols were approved by the Institutional Review Board of the University of Pennsylvania School of Medicine. A Certificate of Confidentiality was obtained from the Department of Health and Human Services as an additional safeguard.
At the index visit, the physician was asked to complete a brief assessment of the patient’s condition at that visit. The physician rated the patient’s level of depression at that visit on a four point scale: “none at all,” “mild,” “moderate,” or “severe.” For this investigation, physician identification was defined as including ratings of “mild,” “moderate,” or “severe.” Next the physician was asked to indicate whether any of the following were provided for the patient at the index visit or any time in the past 6 months: “provided counseling / supportive listening for depression,” “tried to refer to a mental health specialist,” and “prescribed psychotropic medicine for depression, anxiety, or sleep.” Physicians were asked to provide a reason for not prescribing medication or counseling if the patient was thought to be depressed by checking as many reasons as applied from a list or by writing in a reason of their own. Physicians were asked to rate how well they knew the patient.
We obtained information from the respondents on age, gender, ethnicity, marital status, living arrangements, level of educational attainment, and the number of visits made to the practice for medical care within 6 months of the index visit. Patients who denied being Hispanic or Latino/a were asked to select from choices read to them; namely, “American Indian or Alaska Native,” “Asian,” “Black or African-American,” “Native Hawaiian or Other Pacific Islander,” “White,” or “Other.” Patients who responded that they belonged to another ethnic group were excluded from this analysis. Persons who self-identified as African-American were classified as black for the purposes of this investigation.
The Centers for Epidemiologic Studies Depression (CES-D) scale was developed for use in studies of depression in community samples.21–23 The standard CES-D questionnaire contains 20 items and has been employed in studies of older adults.24, 25 In this study, we employed CES-D as a continuous score but we also categorized patients whose CES-D score was 16 and above as depressed. The CES-D appears to be a valid measure of depressive symptoms among persons from differing ethnic groups.26–28 The Beck Anxiety Inventory (BAI) was employed as a continuous score to measure anxiety symptoms.29–31
Questions from the SF-36 were used to assess functional status.32, 33 The SF-36 has been employed in studies of outcomes of patient care,32–36 and appears to be reliable and valid even in frail elders.37 The SF-36 was scored using previously described techniques.38 Baseline medical comorbidity was measured by summing the lifetime presence of 12 chronic diseases or conditions. The following chronic diseases or conditions were included: myocardial infarction, angina, congestive heart failure, high blood pressure, diabetes, osteoarthritis, stroke, cancer, Parkinson’s disease, hip fracture, vision and hearing problems. We asked patients whether they agreed or disagreed with three statements about depression and its treatment.39 The statements were “I believe depression is a medical problem,” “If my doctor told me I had depression, I could accept that,” and “I would take a medicine for depression if my doctor told me to.”
We compared the characteristics of persons who self-identified as black to persons who self-identified as white, using t-tests or χ2 for continuous or categorical data as appropriate. Our primary dependent variable was identification of the patient as depressed by the doctor at the index visit. To adjust our estimates for potentially influential covariates as well as practice clustering effects, we used generalized estimating equations (GEE) for binary outcomes.40 We also examined identification in relation to whether or not the respondents scored 16 and above on the CES-D,21 using the odds ratio as a measure of association. Consistent with our conceptual framework, we introduced terms in the multivariate models to represent age, gender, marital status, level of educational attainment, functional status, physical health, and depressive and anxiety symptoms. Subsequent models included terms for attitudes about depression and its treatment and familiarity with the practice (as represented by the patient’s report of the number of visits made to that practice in the 6 months prior to interview and the doctor’s rating of how well they know the patient) that were hypothesized to be mediators in our conceptual framework. In subsequent analyses, we restricted our attention to the persons whom the physician rated as depressed with report of active management as the dependent variable. Finally, we tabulated physician reasons for not prescribing medication or counseling for patients identified as depressed.
Table 1 compares the characteristics of black and white patients in the sample. Proportionately more black patients are women and unmarried. There were 3 persons who self-identified as “other” for ethnicity and were excluded. Black patients were significantly more likely than white patients to report poorer physical and social functioning. Proportionately fewer black patients were rated as depressed by doctors or were reported to have depression actively managed within 6 months of the index visit.
Black patients who were identified as depressed, when compared to white patients identified as depressed, were more likely to report worse physical and social functioning, and bodily pain (Table 2). Physicians rated that they knew depressed black patients equally well as white patients, but doctors were more likely to report that they knew black patients well who were rated as depressed than were black patients who were not rated as depressed. Black patients who were not rated as depressed by the physician had poorer physical and role emotional functioning when compared to white patients not identified as depressed. Figure 2 illustrates detection rates according to CES-D strata and ethnicity. Black patients were less likely to be identified as depressed across the entire range of CES-D strata. Among persons who scored above the threshold on the CES-D, black patients were less likely than white patients to have been identified as depressed (odds ratio (OR) = 0.48, 95% confidence interval (CI) [0.26, 0.88]).
Black patients who were actively managed reported statistically significantly higher depression scores than white patients who were actively managed, and reported poorer functioning on several measures (Table 3). Black patients who were actively managed made more visits to the primary care office than whites who were actively managed.
After adjustment with GEE to account for clustering and potentially influential covariates including severity of depression symptoms, black patients were 0.25 times as likely (95% confidence interval (CI) [0.17, 0.39]) to have been identified as depressed (Table 4). Black patients were about one-half as likely as white patients to have been actively managed (odds ratio = 0.57) adjusting for potentially influential covariates, although confidence bounds of the point estimate included the null (95% CI [0.19, 1.77]).
Physicians provided reasons for not actively managing the patient’s depression in the 6 months prior to the index visit among the patients they identified as depressed. The most common reason was that the depression was too mild (6 of 12 black patients and 9 of 25 white patients). Next most commonly cited reasons were that the depression represented a temporary adjustment reaction (2 of 12 black patients and 4 of 25 white patients) and that the patient would be reluctant to accept the diagnosis of depression (3 of 12 black patients and 2 of 25 white patients).
In this primary care sample, black patients were less likely to have been identified as depressed than white patients. This association persisted even after controlling for potentially influential variables including severity of depressive symptoms and level of functioning. Black patients were also less likely than white patients to be actively managed after controlling for potentially influential variables; however, the association approximated but did not reach standard levels of statistical significance. Black patients identified by their doctor as depressed and actively managed were more likely to be functionally impaired than were white patients. These results are all the more remarkable because we have asked doctors to report on their care of persons they identify as depressed. Our study builds on prior work9, 18, 41 and suggests that patient ethnicity may play a role in the identification and active management of depression among older adults who present in the primary care setting.
Before putting our results in clinical and research context, the limitations should be discussed. Our study was based on practices that participated in a research study and so may not be representative of all practices. The responses to the survey instruments do not necessarily reflect the actual discussion the patient had with the physician during the office visit when the patient was rated by the physician. In other words, we cannot be certain the extent to which patients of different ethnic groups may express their symptoms differently during physician encounters. We did not have ratings of patient behavior or symptoms from clinical observers other than the patient’s primary care clinician. Despite limitations, our study design is associated with several strengths and the findings deserve attention. Although limited to practices in a single geographical area (Baltimore, Maryland), we attempted to create a representative sample by random calling of physicians based on a sampling frame provided by a professional organization, included multiple practices, and sampled from both urban and suburban areas. The data from physicians are nearly complete (97% of the participants were rated by their doctor). We were able to adjust our measures of association for ratings of how well the physicians knew the patient and other potentially influential covariates. Because we linked patient data to whether the physician reported that they had actively managed the patient’s depression within 6 months of interview, we did not have to depend on chart reviews.
The Institute of Medicine report “Unequal Treatment” reviewed the medical literature on the extent and sources of disparities in health behaviors and outcomes across ethnic groups.42 Despite the observed variation in recognition and treatment of psychiatric disturbances according to ethnicity,9 empirical studies have not typically focused on the patient-physician encounter in studying observed differences in rates of antidepressant use, seeking specialty mental health treatment, or discussing a mental health problem with a general medical health care provider.1, 2, 42
Few studies have focused on older adults to assess the relationship between physician ratings, patient characteristics, and identification and active management of depression. Miranda and Cooper found that Latino and African-American patients were no less likely to be offered treatment for depression by primary care physicians, yet they were less likely to actually receive appropriate care for depression.43 Few older adults were included in that study (e.g., only 2 African-American patients were aged 65 years and older). Borowsky and colleagues reported that black patients were less likely to be identified as having a mental health problem by primary care physicians.44 That study was not focused on older adults or on the specific diagnosis of depression. Sirey and coworkers reported that white patients were much more likely than black patients to receive a recommendation for an antidepressant,45 but did not include adults older than 65 years and did not focus on the primary care setting. Studies of older adults in public housing 46 and in long-term care47 showed that older African-Americans were less likely to use available community mental health services, but no study of recognition has focused on older adults in primary care settings as we have done here.
For clinicians it may be easier to determine if a patient has a symptom of depression than to determine the severity of the symptom. When judgment about uncertain elements of the clinical examination are required, patient characteristics can have a greater effect on the final assessments. Physicians caring for black patients should be aware that there is a tendency for depressive symptoms to be judged as not severe. Physicians might introduce this fact into their interviews when appropriate and determine if this leads to a different conversation with their black patients. Acknowledging that the possibility of a discrepancy occurs may be the first step to improving management.
The recognition and management of depression in primary care settings is a negotiated process between the patient and the primary care physician. Given the competing demands of practice,48 the common uncertainty inherent in the diagnosis of depression in primary care settings, and differing perceptions of the doctor-patient encounter across ethnic groups,41, 49 physicians may take their cue for identification and management decisions from their assessment of the likelihood that a patient will accept the diagnosis or treatment recommendations. In addition, physicians may interpret symptoms of persons as too mild to treat when the patient is black. Physicians and patients may collude not to treat depression, ascribing symptoms to other causes such as social conditions. We are carrying out analyses of open-ended interviews of the sample to understand how older adults themselves think about the nature, treatment, and outcome of depression. Physicians and patients in primary care settings come to the encounter with attitudes, expectations, and values that may differ markedly from physician to physician as well as between physician and patient. Sorting out the multiple sources of disparity will require fine-grained studies of how characteristics of providers, patients, and systems of care influence the interplay of physician, patient, and environment.
The Spectrum Study was supported by grants MH62210, MH62210, and MH67077 from the National Institute of Mental Health. Dr. Bogner was supported by a NIMH Mentored Patient-Oriented Research Career Development Award (MH67671-01) and is a Robert Wood Johnson Foundation Generalist Physician Scholar (2004–2008).
Financial disclosures: None