To search for factors related to practice setting, we refined our initial search strategy with the MeSH terms primary health care, family practice, and health services. We also hand-checked bibliographies to find potential articles.
Study selection and data extraction
Two investigators (AKD, MO) independently reviewed abstracts of the articles retrieved and excluded articles that did not fulfill the criteria to be relevant to the topic of depression in African American patients. Articles were excluded if they did not focus on US populations, African Americans, depressive disorders, and clinical settings, or if they did not report original data. Differences between the 2 reviewers were resolved through consensus after full-text review of the article.
Additional articles were defined by 2 other investigators (HLC, MMW) who provided peer review and identified potential articles in bibliographies. For each article, we classified the barriers described as related to diagnosis, management, or both and to patient, physician, and treatment-setting factors.
Results
The initial search using the MeSH terms African Americans and depressive disorder with adult or adolescent returned 156 articles. We found a total of 73 unique articles by refining our Medline search with additional MeSH terms. Of these publications, 12 fulfilled our criteria as relevant to the topic of diagnosing and managing depression in African American patients.
Our hand-checking of bibliographic references found an additional 12 articles that met our relevancy criteria. We examined each of the 24 articles (TABLE 1) to determine the types of barrier studies and whether the factor was related to the detection of depression, its management, or both.
TABLE 1
Selected studies on managing depression in African Americans
| AUTHOR | SAMPLE (% AFRICAN AMERICAN) | STUDY OUTCOMES | MAJOR FINDINGS |
|---|---|---|---|
| Borowsky et al3 | 19,309 adult primary care patients (13%) | Detection of a mental health problem by internists and family physicians | African American patients who have major depression have a lower rate of being detected than their white counterparts |
| Brown et al28 | 272 depressed adult primary care patients (44%) | Differences in clinical characteristics, health impairments, health beliefs, stressful life events, and social support between African American and white subjects enrolled in a clinical trial of depression | In comparison to white persons, African Americans are more likely to experience somatization, greater health impairment, greater perception of less control of their health status and greater number of stressful life events in the previous 6 months |
| Brown et al29 | 160 depressed adult primary care patients (43%) | Differences in treatment outcomes from a clinical trial of standardized psychotherapy and pharmacotherapy | Both African American and white patients are effectively treated by psychotherapy and antidepressant medications, but African American subjects have poorer outcome in physical functioning |
| Brown et al30 | 865 adult African American persons from a community sample (100%) | Rate of major depression compared with demographic, sociocultural, familial background, and health-related risk factors | The strongest predictors of major depression are self-reported poor or fair physical health and being 20 to 29 years of age |
| Cooper et al31 | 829 depressed adult primary care patients (12%) | Attitudinal measures of acceptability of antidepressant medication and individual counseling | African Americans are less likely than white persons to find antidepressant medication acceptable |
| Cooper-Patrick et al23 | 1816 adult primary care patients (45%) | Patients’ ratings of physicians participatory decision making style | African American patients rate their visits as less participatory than their white counterparts and race-concordant patient-physician relationships are more participatory than race-discordant relationships |
| Cooper-Patrick et al32 | Focus group consisting of 16 patients with a recent episode of depression (50%) | 16 categories of comments regarding treatment of depression were identified from audiotaped discussions | African American patients provided more comments about spirituality and stigma and were less concerned with the relation between physical health and depression than white patients |
| Dunlop et al5 | 7690 subjects aged 54 to 65 years from national probability sample (17%) | Rates of major depression with socio demographic characteristics, self-reported health needs, functional limitations, and economic resources as explanatory variables | African Americans have a greater rate of major depression compared to whites, but have a significantly lower rate after adjustments for health needs (such as comorbid physical problems) and economic access (such as income and health insurance) |
| Fabrega et al33 | 5198 adult community mental health center patients (16%) | Rates of major depression and comorbid psychiatric diagnoses | African Americans have a higher rate of comorbid major depression and substance-use disorders than their white counterparts |
| Ford et al34 | Community-based sample of 7092 adults who had who had a mental health or substance abuse problem and received care in nonpsychiatric settings (29%) | Patient self-reported discussion of a mental health problem or problem with alcohol or drugs | No significance differences between the rates of African Americans and whites discussed emotional or mental health problems with their physicians |
| Grant et al35 | National probability sample of adult non-institutionalized US population (NR) | Rates of major depression and alcohol use disorders stratified by demographic variables | The association between alcohol abuse and major depression was greater among African Americans than among non–African Americans |
| Hanson et al36 | 60 adult patients undergoing psychiatric evaluation (50%) | Congruence between physicians’ and patients’ ratings of depression during an intake assessment | Concordance of symptoms ratings is lower between white psychiatrists and African American patients than with white psychiatrists and white patients |
| McKinlay et al37 | 128 primary care physicians (25%) | Diagnostic assessment of videotaped patient presentations of depression and another medical condition | Demographic attributes of patients did not affect diagnostic accuracy, and white physicians were almost twice as likely as their African American counterparts to diagnose depression correctly |
| Miranda et al38 | 205 adult public-sector gynecologic patients (30%) | Rates of psychiatric disorders along with extent of primary care services and perception of communication with primary care provider | In a largely minority (82%) patient population (with no reported differences among racial/ethnic groups), 1 out of 5 patients endorsed major depression and fewer than half had access to comprehensive primary medical services |
| Miranda et al39 | 1269 adult primary care patients (7%) | Clinical outcome, appropriateness of care, and employment for patients enrolled into a clinical trial of 2 quality improvement interventions with modest adaptation to minority patients | African American patients, in contrast to their white counterparts, experienced a significant decrease in probable depression from baseline |
| O’Malley et al40 | Population-based sample of 1202 women (83%) | Rates of care of depression, extent of primary care services, quality of physician-patient relationship | In a largely African American sample (with no reported differences between racial/ethnic groups), comprehensive primary care delivery (including counseling) and self-reported view of physician as respectful are associated with physician inquiry and treatment of depression |
| Rollman et al41 | 204 adult primary care patients (25%) | Processes of depression care and patient outcome following screening and treatment recommendations to physicians | No differences in treatment patterns and outcomes were found between white and African American patients, except for increased rate of documented counseling by physicians among whites |
| Sleath et al42 | 508 adult outpatients (NR) | Patient expression of symptoms from audiotaped medical encounter and physician perception of health from survey | Among all factors, only patient expression of emotional symptoms among African American patients influenced psychotropic prescribing |
| Steffens et al43 | 113 patients age 60 years or older (11.5%) | Annual rate of enrollment into a geriatric depression research program based on race and ethnicity | Active community outreach and enrollment increased representation of African Americans by threefold over a 2-year period |
| Sussman et al1 | 3004 adult subjects from a community-based sample (38%) | Treatment seeking behavior for subjects who have current depression | African Americans are less likely to seek care for depression than whites, with African Americans reporting greater fear of treatment and of being hospitalized than whites |
| Van Hook44 | 321 adult women in primary care settings (22%) | Rate of major depression and reported barriers to treatment | In a multi-ethnic sample (with no reported differences among racial/ethnic groups), commonly reported barriers to seeking help included stigma and perceived separation of primary care and specialty mental health services |
| Wells et al45 | 9585 adult national survey respondents (28%) | Access to treatment for alcoholism, drug abuse and, mental health care; unmet need for care; satisfaction with care and use of active treatment in the prior year | Among those with perceived need for mental health services, African Americans were more likely to report no access to care than whites and less likely to receive active treatment |
| Wohl et al46 | 20 matched adult depressed African American and white patients (50%) | Symptom pattern and severity of depression | No difference in symptom severity was found between African Americans and whites, and African Americans were more likely to experience diurnal variation in their depression |