Depression in African Americans: Breaking barriers to detection and treatment
Community-based studies tend to ignore high-risk groups of African Americans.
Patient attributes. A number of patient attributes have been examined that may explain the lower rate of mental health services provided in primary care. Significant research has been undertaken on African American attitudes toward and beliefs about mental health treatments. Cooper-Patrick and colleagues conducted focus groups for African American and white patients as well as health care professionals. In questions related to depression and treatment preferences, African American patients expressed more concerns about stigma and spirituality than did white patients.32
In related research, a survey of African American patients recruited from primary care offices indicated they were less likely to find antidepressant medication acceptable than white patients in primary care.31 Such attitudinal differences may explain why African Americans use antidepressants less commonly than whites, even when primary care physicians make similar recommendations for both groups.52 As yet unstudied is the extent to which sensational reports about antidepressant side effects may cause persons already skeptical about the care they receive to discontinue treatment.
Another reason African Americans may avoid or discontinue antidepressant treatment is that they tend to tolerate certain classes of psychotropic medications poorly. Strickland and colleagues found that African Americans are more likely than whites to be “poor metabolizers” of tricyclic antidepressants.53 African Americans treated with tricyclic antidepressants will therefore experience higher plasma levels per dose than whites, and an earlier onset of action. African Americans are also more likely to experience side effects, which may lead to treatment nonadherence.
Few studies have examined the tolerability of newer class of antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs), for African Americans. More research is required to determine whether antidepressant side effects or other experiences with psychotropic medications are a reason for the lower rates of antidepressant use among African American patients in primary care. Educating patients about antidepressants, their onset of action, and side effects may reduce some of these barriers and prevent early discontinuation of antidepressant therapy.54
Poverty and its associated psychosocial factors may also contribute to the lower quality of mental health care among African Americans. Miranda and colleagues found this to be so for African American women receiving primary care in obstetric-gynecologic clinics.47 They have argued that clinical case management is needed as a component of effective mental health treatment for primary care patients who are poor and likely to face significant negative life events.
Practice-setting attributes. Few practice-setting factors have been examined in relationship to the disparities in depression treatment faced by African Americans. O’Malley and colleagues examined whether primary care physicians who were evaluated as having comprehensive medical services by low-income African American women were more likely to provide treatment for depression.40 Comprehensiveness was determined by the ability to meet all health needs, thoroughness of physical exam, and provision of counseling and screening services. In a survey study, they found that comprehensiveness of medical services was correlated to being asked about and being treated for depression.
Interventions in primary care
Concerted efforts to improve quality of care can reduce the mental health burden of undetected depression for African Americans as well as other ethnic and racial groups. African American and white primary care patients both appear to respond equally to standardized psychotherapy and pharmacotherapy for major depression.29
In a randomized control trial to improve the quality of depression management in primary care, no significant differences existed between white and African American participants in the process of depression care or clinical outcomes, although both groups had less than optimal recovery rates.41 One randomized clinical trial included modified interventions to target the mental health needs of low-income minority primary care patients. The interventions included educating clinicians about depression; teaching nurses to educate, assess, and follow-up depressed patients; and making cognitive behavioral therapy available. Patients and physicians selected the treatment. Modification for minority patients was modest and included translations and cultural training for clinicians.
Using these approaches, African American participants were more likely than whites to have better depression outcome at 6 and 12 months.39 These studies indicate that both general interventions to depression care and small modifications for minority patients can lead to improved health outcomes among African American patients.
It may be unreasonable to believe that simply seeking to improve the primary care assessment and treatment of depression in African Americans will eliminate racial differences in the health outcomes of depressed adults. Reform is also clearly needed in health care financing and in broader social welfare policy as it affects the lives of depressed minority populations. However, primary care providers who are aware of the risk of racial disparities in the recognition and treatment of depression and work to provide treatments that are tailored to the individual’s needs can help to reduce the significant burden of depression (TABLE 2).
