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.