Does Race Affect Depression Treatment in Primary Care?
Race-based disparities in the way patients with symptoms of depression are sometimes treated may be explained by the words physicians choose to communicate with them.
That physicians’ word choice matters a great deal in the doctor-patient relationship is not news to psychiatrists, of course, but a new study suggests that primary care physicians might benefit from training that helps them communicate better with patients from ethnic groups different from their own.
Lisa Cooper, M.D., M.P.H., points out that primary care doctors who fail to discuss mental health issues with their African-American patients are also unlikely to refer patients for specialty psychiatric care.
Cooper, an associate professor of medicine and of health policy and management at Johns Hopkins School of Medicine and its Bloomberg School of Public Health, reported her findings in August at the National Medical Association’s annual convention in Honolulu.
Cooper enlisted 31 primary care physicians and 252 of their patients (110 whites and 142 blacks) from the Baltimore and Washington, D.C., areas. Of the study sample, 72 percent of the blacks were women, and 65 percent of the whites were women.
The physicians represented 15 community-based group practices, both managed care and fee for service. Patients were recruited from the physicians’ waiting rooms over a one- to two-day period, with the physicians’ permission.
There was a statistically significant difference in the racial breakdown of the participating physicians, with 73 percent of the black subjects but just 32 percent of the white subjects seen by a black primary care doctor.
Data were collected at three points. A previsit survey gathered patient demographic data, health status information, and depression level using the CES-D (Center for Epidemiologic Studies Depression Scale). Intravisit data collection included an audiotape of physician-patient communication, with content coded by the Roter Interaction Analysis System. The postvisit survey gathered “physician reports of mental health management and perceptions of patients’ complaints and psychological receptivity,” Cooper noted.
‘Depression Talk’ Measured
The physician-patient encounters were assessed for the number of statements categorized as “depression talk,” for which Cooper gave a few examples. On a physician’s part, a statement such as “Maybe we should have you see a professional counselor to help you sort through some of these issues” would qualify. So might the comment, “It might just be a matter of getting you on the right amount of antidepressant medication.”
If the patient made a statement such as “I’ve been taking Trazadone,” it would be coded as depression-related talk, as would “I’m feeling tired all the time. I like to look on the bright side, but it seems that lately it’s harder to do.”
Communication also was categorized according to whether it was biomedical, psychosocial, emotional, or partnership-building.
Cooper found a significant difference in the number of depression-related statements initiated by physicians during the visits, with an adjusted mean of 6.04 statements when the patient was black and 8.47 when the patient was white. There was also a substantial racial difference when patient-initiated statements were assessed. Black patients had a mean of 12.17 such statements during a primary care encounter, while their white counterparts offered 20.19 such statements.
On other related types of communication measured, racial disparities were also evident, Cooper pointed out. For “psychosocial talk,” the mean number of statements was 13.09 for white patients, but just 2.26 for blacks. Looking at “emotional talk,” she found a similar pattern, with statements made to and by white patients showing a mean of 10.02, and black patients 2.68. There was much less discrepancy for statements labeled “partnership-building,” where the means were 10.89 for whites and 8.37 for blacks.
In general, she emphasized, primary care physicians engaged in less patient-centered communication and exhibited more “verbal domination” when the patient was black.
These racial disparities, Cooper said, were not limited to the communications during visits. Physicians’ reports of postvisit management showed a similar pattern. For example, 45 percent of the primary care physicians concluded that their white patients were depressed, while 31 percent thought their black patients were. In addition, 18 percent prescribed an antidepressant for white patients, but only 6 percent did so for black patients. Twenty percent of white patients the physicians were managing for mental health issues were referred to a mental health specialist, while 7 percent of black patients were.
There was little difference in patient-centered communication measures based on whether the physician and patient were of the same or different races.
Possible Explanations
The patterns were clear, Cooper stated. When black patients visit their primary care doctor, both they and their physicians are less likely to introduce talk about depression, emotions, or psychosocial issues. Identifying the cause of these disparities is less clear, she noted, though explanations likely include less recognition of depression symptoms in black patients, primary care physicians’ greater likelihood to attribute depression-related symptoms to stress when black patients discuss them, and race-based assumptions that physicians make about their patients’ attitudes toward mental health care. She did cite limits of her study including that she looked at only one patient visit, and depression measures were not diagnostic ones.
These findings are important for psychiatrists, she told Psychiatric News, because if primary care doctors—who treat a substantial number of people with mental disorders—are failing to discuss depression symptoms and their treatment with their African-American patients, they are also unlikely to refer these patients for specialty psychiatric care—at least not until their patient’s disorder becomes severe.
Cooper offered several strategies that could narrow this depression-care gap. These included training programs designed to enhance primary care physicians’ communication skills so they are more culturally sensitive and more apt to operate from a patient-centered perspective. She also cited the need to educate minority patients about the value of being active participants in their medical care.
In a future study Cooper plans to assess racial differences in the way patients describe symptoms that may signal depression. For example, it may be that black patients are more likely to focus on physical than emotional symptoms, she noted. ▪
