The acceptability of treatment for depression among African-American,Hispanic, and white primary care patients

BACKGROUND: Ethnic minority patients are less likely than white patients to receive guideline-concordant care for depression. It is uncertain whether racial and ethnic differences exist in patient beliefs, attitudes, and preferences for treatment. METHODS: A telephone survey was conducted of 829 adult patients (659 non-Hispanic whites, 97 African Americans, 73 Hispanics) recruited from primary care offices across the United States who reported 1 week or more of depressed mood or loss of interest within the past month and who met criteria for Major Depressive Episode in the past year. Within this cohort, we examined differences among African Americans, Hispanics, and whites in acceptability of antidepressant medication and acceptability of individual counseling. RESULTS: African Americans (adjusted OR, 0.30; 95% CI 0.19-0.48) and Hispanics (adjusted OR, 0.44; 95% CI, 0.26-0.76) had lower odds than white persons of finding antidepressant medications acceptable. African Americans had somewhat lower odds (adjusted OR, 0.63; 95% CI, 0.35-1.12), and Hispanics had higher odds (adjusted OR, 3.26; 95% CI, 1.08-9.89) of finding counseling acceptable than white persons. Some negative beliefs regarding treatment were more prevalent among ethnic minorities; however adjustment for these beliefs did not explain differences in acceptability of treatment for depression. CONCLUSIONS: African Americans are less likely than white persons to find antidepressant medication acceptable. Hispanics are less likely to find antidepressant medication acceptable, and more likely to find counseling acceptable than white persons. Racial and ethnic differences in beliefs about treatment modalities were found, but did not explain differences in the acceptability of depression treatment. Clinicians should consider patients' cultural and social context when negotiating treatment decisions for depression. Future research should identify other attitudinal barriers to depression care among ethnic minority patients.     

Ethnic and racial differences in diabetes care: The Insulin Resistance Atherosclerosis Study

OBJECTIVE: Diabetes and its complications disproportionately affect African Americans and Hispanics. Complications could be prevented with appropriate medical care. We compared five processes of care and three outcomes of care among African Americans, Hispanics, and non-Hispanic whites. RESEARCH DESIGN AND METHODS: We used data from the Insulin Resistance Atherosclerosis Study (1993-1998) of participants with known diabetes. African Americans and Hispanics were compared with non-Hispanic whites from the same region. Five process measures (treatment of diabetes, hypertension, hyperlipidemia, albuminuria, and coronary artery disease) and three outcome measures (control of diabetes, hypertension, and hyperlipidemia) were evaluated. RESULTS: Comparison groups were similar in baseline characteristics. African Americans and Hispanics were equally likely as their non-Hispanic white comparison group to receive treatment for diabetes, hypertension, hyperlipidemia, albuminuria, and coronary artery disease, although treatment rates for hyperlipidemia and albuminuria were poor for all groups. African Americans were more likely to have poorly controlled diabetes (HbA(1c) >8.0%: OR 2.23, 95% CI 1.26-3.94). Both African American and Hispanics were significantly more likely to have borderline or poorly controlled hypertension than non-Hispanic whites (blood pressure >130-140/85-90 or >140/90 mmHg: African American/non-Hispanic white OR 3.22, 95% CI 1.57-6.59; Hispanic/non-Hispanic white 3.14, 1.35-7.3). CONCLUSIONS: The rates of treatment for diabetes and associated comorbidities are similar across all three ethnic groups. Few individuals in any ethnic group received treatment for hyperlipidemia and albuminuria. Ethnic disparities exist in control of diabetes and hypertension. Programs should be tested to improve overall quality of care and eliminate these disparities.     

Patient race and ethnicity in primary care management of child behavior problems: a report from PROS and ASPN. Pediatric Research in Office Settings. Ambulatory Sentinel Practice Network.

BACKGROUND: Minority persons have less access to many specialty treatments and services, possibly because of clinician biases. It is not clear whether any such biases exist in primary care settings, especially for children with psychosocial problems. OBJECTIVES: The objective was to compare primary care recognition and treatment of pediatric psychosocial problems among African American, Hispanic American and European American patients. DESIGN: A survey was made of parents and respective clinicians in primary care offices in two large practice-based research networks (PROS and ASPN) from 44 states, Canada, and Puerto Rico. Mixed regression analyses were employed to control for patient, clinician, and practice effects. SUBJECTS: The subjects were 14,910 children aged 4 to 15 years seen consecutively for non-emergent care by 286 primary care clinicians in office-based practice. MEASURES: Measures were parents' report for sociodemographics and behavioral symptoms using the Pediatric Symptom Checklist, and clinicians' report of psychosocial problems, type, management, and severity. RESULTS: Of the sample, 8.0% were African American youth, 9.5% were Hispanic American youth, and 82.5% were European American youth. After controlling for other factors, race and ethnicity were not associated with any differences in psychotropic drug prescribing, counseling, referral, or recognition of psychosocial problems. Clinicians reported spending slightly more time with minority patients. CONCLUSION: Race and ethnic status were not related to receipt of mental health services for children in primary care offices, suggesting that clinician biases may not be the primary cause of the racial differences in services noted earlier research. Improving services for minority youth may require increasing access to office-based primary care.     

Trends in the rate of depressive illness and use of antidepressant pharmacotherapy by ethnicity/race: an assessment of office-based visits in the United States, 1992-1997

OBJECTIVE: This study was undertaken to determine ethnicity/race-specific (white, black, and Hispanic) population-adjusted rates of US office-based physician visits in which a diagnosis of a depressive disorder was recorded or in which a diagnosis of a depressive disorder was recorded and antidepressant pharmacotherapy was prescribed. METHODS: Data from the National Ambulatory Medical Care Survey for 1992 through 1997 were partitioned into three 2-year periods: 1992-1993, 1994-1995, and 1996-1997. For each 2-year period, data from office-based physician visits for patients aged 20 to 79 years were extracted to assess, by ethnicity/race, (1) the number of visits in which a diagnosis of a depressive illness was recorded (International Classification of Diseases, Ninth Revision, Clinical Modification codes 296.2-296.36, 300.4, or 311) and (2) the number of visits in which a diagnosis of a depressive illness was recorded and antidepressant pharmacotherapy was prescribed. We calculated ethnicity/race-specific rates (per 100 US population aged 20 to 79 years) of office-based visits in which a diagnosis of a depressive disorder was recorded and in which a diagnosis of a depressive disorder was recorded and antidepressant pharmacotherapy was prescribed. The specialty of the reporting physician and the proportion of patients receiving a selective serotonin reuptake inhibitor (SSRI) were also discerned. RESULTS: From 1992-1993 to 1996-1997, the rate of office-based visits (per 100 US population aged 20 to 79 years) in which a diagnosis of a depressive disorder was recorded increased 3.7% for whites (from 10.9 to 11.3; P = 0.001), 31.0% for blacks (from 4.2 to 5.5; P = 0.001), and 72.9% for Hispanics (from 4.8 to 8.3; P = 0.001). The rate of office-based visits in which a diagnosis of a depressive disorder was recorded and antidepressant pharmacotherapy was prescribed increased 18.5% for whites (from 6.5 to 7.7 per 100; P = 0.001), 38.5% for blacks (from 2.6 to 3.6 per 100; P = 0.001). and 106.7% for Hispanics (from 3.0 to 6.2 per 100; P = 0.001). Between 1992-1993 and 1996-1997, use of an SSRI increased among whites and blacks (from 50.0% to 65.8% and from 40.5% to 58.2%, respectively), but declined among Hispanics (from 51.4% to 48.6%; all comparisons P = 0.001). CONCLUSION: By 1996-1997, the population-adjusted rates for Hispanics were within a quartile of those observed for whites, whereas the rates for blacks remained at less than half those observed in whites. The observed divergence in population-adjusted rates by ethnicity/race may reflect the nature of the patient-physician relationship, sensitivity and specificity of diagnostic techniques and instruments, and the wider social context in which an office-based visit occurs, including access to and type of health insurance and coverage for mental health services.     

Quality of mental health care for youth with asthma and comorbid anxiety and depression

OBJECTIVES: Youth with asthma have a high rate of anxiety and depressive disorders, and these comorbid disorders are associated with increased asthma symptom burden and functional impairment. This study examined the rates and predictors of recognition of anxiety and depressive disorders among youth (ages 11 to 17) with asthma who are seen in primary care settings as well as the quality of mental health care provided to those with comorbid anxiety and depression over a 12-month period. METHODS: This study used automated utilization and pharmacy data from a health maintenance organization to describe the rate of recognition of Diagnostic and Statistical Manual of Mental Disorders, edition IV, anxiety and depressive disorders and the quality of mental health care provided for the 17% of youth with asthma and comorbid anxiety and/or depression during the 12-month period prior to diagnosis. Psychiatric diagnoses were based on a telephone version of the Computerized Diagnostic Interview Schedule for Children (Version 4.0). RESULTS: Approximately 35% of youth with 1 or more anxiety and depressive disorders and 43% of those with major depression were recognized by the medical system during a 12-month period. Greater functional impairment (odds ratio [OR] 3.32, 95% confidence interval [CI] 1.25-8.79), higher severity on parent-rated anxiety and depressive symptoms (OR 2.49, 95% CI 1.04-6.00), and a greater number of primary care visits (OR 1.26, 95% CI 1.10-1.44) were associated with significantly higher recognition rates while having Medicaid or Washington state medical insurance was associated with lower rates of recognition (OR 0.27, 95% CI 0.08-0.92). Only approximately 1 in 5 youths with comorbid major depression received an adequate dosage and duration of antidepressant medication, and only 1 in 6 received a minimally adequate number of psychotherapy sessions (> or =4 visits). CONCLUSION: Rates of recognition of comorbid anxiety and depressive disorders are low in youth with asthma and few youth with asthma and comorbid anxiety and depression receive guideline-level mental health treatment.     

Physician referrals to physical therapy for the treatment of musculoskeletal conditions

OBJECTIVES: To identify factors associated with orthopedic surgeons' and primary care physicians' referrals to physical therapy (PT) for musculoskeletal conditions. DESIGN: Cross-sectional analysis of National Ambulatory Medical Care Survey data. SETTING: US office-based physician practices. PARTICIPANTS: Visits to primary care physicians (N=4911) or orthopedic surgeons (N=4201) for musculoskeletal conditions. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Whether a PT referral was made. RESULTS: After controlling for diagnosis, illness severity, and PT supply, insurance status and physician characteristics remained strong predictors of PT referral. Primary care visits covered by Medicaid or a managed care plan were less likely to result in PT referral than were visits covered by private insurance or a nonmanaged care plan. Orthopedic surgeon visits covered by workers' compensation or managed care were more likely to result in PT referral than were visits not covered by workers' compensation or not covered by managed care. Osteopathic primary care visits were more likely than allopathic primary care visits to result in PT referral. Given identical visit characteristics, orthopedic surgeon visits were more likely than primary care visits to result in PT referral. CONCLUSIONS: Significant differences exist in orthopedic surgeons' and primary care physicians' referrals to PT, both within and across specialties. Variation in PT referral may be indicative of problems with access and/or inappropriate referral.     

Resolving disparities in antidepressant treatment and quality-of-life outcomes between uninsured and insured primary care patients with depression

BACKGROUND: Efforts to improve primary care depression treatment should penetrate to vulnerable uninsured populations. OBJECTIVE: To assess a primary care intervention's impact on treatment and quality-of-life outcomes in uninsured and insured depressed patients during the acute treatment phase. RESEARCH DESIGN: Twelve community primary care practices were randomized to 'enhanced' (intervention) and usual care conditions. Physicians, nurses and administrative staff in enhanced care practices received training to improve detection and management of depression. SUBJECTS: In 1996 to 1997, 383 nonelderly depressed patients who were either uninsured or covered by private insurance/Medicaid were enrolled; 343 (89.6%) completed six-month follow-up. MEASURES: Adequate pharmacotherapy (>or=3 months of antidepressants at therapeutic doses); adequate psychotherapy (>or=8 counseling visits); improvement in mental-health-related-quality-of-life (MHQOL), assessed by Mental Component Summary scale for SF-36. RESULTS: Multivariate results showed that 54.6% of uninsured enhanced care (UEC) patients received adequate pharmacotherapy, compared with 14.3% of uninsured usual care (UUC) patients (P = 0.0005); however, receipt of adequate psychotherapy was comparable between these two groups (18.2% UEC, 11.9% UUC; P = 0.42). Intervention effects on insured patients' treatment were modest to minimal. Among usual care patients, the insured had 5.4 points greater improvement in MHQOL at 6 months than the uninsured (12.4 points insured, 7.0 points uninsured; P = 0.02); however, among patients receiving the intervention, the insured and uninsured had comparable MHQOL improvement (12.3 points insured, 11.6 points uninsured; P = 0.76). CONCLUSIONS: The intervention improved antidepressant treatment rates in uninsured patients and helped resolve quality-of-life outcome disparities observed between insured and uninsured patients receiving usual care.     

Clinical aspects of depression

In recent years, clinicians and epidemiologists have examined the differences between depressed patients in primary care and psychiatric settings. Although evidence to support antidepressant efficacy is largely derived from studies of major depression, many patients in primary care settings fall into "nonmajor" depression diagnostic categories. In deciding when to initiate treatment, functional change may be even more important than discrete symptom profiles. Recognizing and treating depression as a comorbid condition in patients with other medical illnesses represents an additional challenge for the primary care physician. Variations in the clinical presentation of depression based on gender, age, culture, or personality must also be considered.     

Trends in obesity-related counseling in primary care: 1995-2004

OBJECTIVE: We sought to ascertain whether the percentage of visits in which physicians provided obesity-related counseling services increased between 1995 and 2004. METHOD: Data came from the 1995 to 2004 National Ambulatory Medical Care Survey, an annual national survey of visits to office-based physicians. Analyses are restricted to visits by adults to a primary care physician (PCP; general/family or internal medicine). The main outcome measure is the percentage of visits to physicians where patients were counseled about exercise, diet/nutrition or weight loss. RESULTS: Sample sizes ranged from 9,583 to 14,071. In 2003/2004, approximately 20% of visits to PCPs included counseling for diet/nutrition, 14% for exercise, and 6% for weight loss. Approximately 24% of visits included at least one of these types of counseling. The odds of receiving counseling for any of these services were 22% lower in 2001/2002 and 18% lower in 2003/2004 compared with 1995/1996. Patients who went to the doctor for weight-related concerns or with an obesity-related diagnosis were more likely to receive counseling than the general population. Longer visits were associated with greater probability of obesity-related counseling. CONCLUSIONS: Obesity-related counseling does not appear to be a substantial part of the services provided by physicians. Further efforts in developing interventions that can be used by physicians and demonstrating their effectiveness within clinical practice are needed.     

Tension-type headache

Tension-type headaches, the most prevalent form of headache, are differentiated as being either episodic or chronic. The episodic form is a physiologic response to stress, anxiety, depression, emotional conflicts, fatigue, or repressed hostility. Treatment focuses on the use of over-the-counter or prescribed simple analgesics for pain relief. Successful treatment of the chronic form depends on recognition of depression or persistent anxiety states. Primary care physicians can effectively manage most of these patients with nonhabituating anxiolytic or antidepressant medications; however, referrals for psychotherapy may be required in some cases. When tension-type headaches occur in children and adolescents, the physician must explore the patient's family and social relationships as well as school performance. In addition to nonhabituating drug therapies, family counseling and biofeedback may be helpful. In coexisting migraine and tension-type headaches, nonhabituating analgesics may be used for the relief of acute pain; the use of ergotamine and triptans should be restricted to relief of the hard or sick headache. Tricyclic antidepressants or monoamine oxidase inhibitors are the gold standards for prophylaxis, although the selective serotonin reuptake inhibitors may be indicated in less severe cases. Several forms of biofeedback have also proved effective. Nonetheless, some patients with this form of headache may require psychiatric treatment for severe depression.     

Tension-type headache

Tension-type headaches, the most prevalent form of headache, are differentiated as being either episodic or chronic. The episodic form is a physiologic response to stress, anxiety, depression, emotional conflicts, fatigue, or repressed hostility. Treatment focuses on the use of over-the-counter or prescribed simple analgesics for pain relief. Successful treatment of the chronic form depends on recognition of depression or persistent anxiety states. Primary care physicians can effectively manage most of these patients with nonhabituating anxiolytic or antidepressant medications; however, referrals for psychotherapy may be required in some cases. When tension-type headaches occur in children and adolescents, the physician must explore the patient's family and social relationships as well as school performance. In addition to nonhabituating drug therapies, family counseling and biofeedback may be helpful. In coexisting migraine and tension-type headaches, nonhabituating analgesics may be used for the relief of acute pain; the use of ergotamine and triptans should be restricted to relief of the hard or sick headache. Tricyclic antidepressants or monoamine oxidase inhibitors are the gold standards for prophylaxis, although the selective serotonin reuptake inhibitors may be indicated in less severe cases. Several forms of biofeedback have also proved effective. Nonetheless, some patients with this form of headache may require psychiatric treatment for severe depression.     

Insurance policies and perceived quality of primary care among privately insured patients: do features of managed care widen the racial, ethnic, and language-based gaps?

CONTEXT: Little is known about whether some features of managed care widen disparities in patients' evaluations of primary care. OBJECTIVES: We investigated whether the magnitudes of racial and ethnic/language-based differences in patients' evaluations of the quality of primary care vary by capitation and gatekeeping. DESIGN: We used a telephone survey of a representative sample of the US noninstitutionalized population, Community Tracking Study Household Survey 1998-1999, and Followback Survey of respondents' insurance administrators. SETTING AND PARTICIPANTS: Our sample was privately insured adults who saw a physician at least once during the year preceding the interview and whose last visit was to a primary care physician. MAIN OUTCOME MEASURES: We measured patients' evaluations of (1) how well the physician listened, (2) how well the physician explained, and (3) how thorough and careful the physician was during the last visit. RESULTS: Significant white-minority differences emerge more often in plans using capitation or gatekeeping than in other plans. The gaps in patients' evaluations of their primary care providers' (PCP) explanations and thoroughness between whites and Hispanics interviewed in English are larger when the PCP is capitated than when the PCP is not capitated. The gap in the evaluations of their PCP's explanations by whites and Hispanics interviewed in English is larger in plans that require referrals for specialist visits than in other plans. The magnitude of racial and ethnic/language-based gaps for Hispanics interviewed in Spanish, blacks, and Native American/Asian/Pacific Islanders do not differ by capitation and gatekeeping. CONCLUSION: English-speaking Hispanics' perceptions of the quality of primary care may be more dissimilar from whites' when capitation or gatekeeping are used than when these policies are not used.     

Anxiety disorders: treatment considerations

Anxiety disorders are among the most prevalent and disabling psychiatric disorders. Today patients have a plethora of treatment options to manage these potentially disabling and costly psychiatric disorders. Anxiety disorders represent a large portion of primary care visits and diverse practice settings. Nurses are in key positions to identify symptoms of various anxiety disorders, initiate appropriate treatment, or refer patients for treatment. Families play a key role in successful treatment planning and must be an integral part of the health care team. Major nursing interventions must focus on making an accurate diagnosis, initiating appropriate treatment, and facilitating a higher level of functioning and quality of life.     

Considerations in the management of the patient with comorbid depression and anxiety

PURPOSE: To provide clinicians with guidelines for the assessment, evaluation, diagnosis, and management of comorbid depression and anxiety in the primary care setting. DATA SOURCES: Research-based articles in the medical and psychiatric literature, literature reviews by experts in the field, and DSM-IV-TR. CONCLUSIONS: Comorbid anxiety and depression occurs at a high rate in primary care, and is costly to both the individual and to society. These patients most often present in primary care settings, have more severe symptoms, and require more health care resources. The presentation of depression and anxiety together pose complicated diagnostic and treatment challenges, leading to inadequate diagnosis and treatment resulting in unnecessary patient distress and increased utilization of health care services. IMPLICATIONS FOR PRACTICE: This article is a review of comorbid depression and anxiety with a focus upon societal and patient significance and impact, under recognition and under treatment, diagnostic challenges, medical comorbidity, treatment considerations, and educational strategies. Effective assessment, evaluation, diagnosis and treatment can lead to better treatment outcomes and improved quality of life in primary care patients.     

Prayer as a complementary health strategy for managing HIV-related symptoms among ethnically diverse patients

Data were analyzed from an ethnically diverse convenience sample comprising 1071 adults participating in a multisite study. Older African Americans, Hispanics, and females were more likely to use prayer as a complementary health strategy for HIV-related anxiety, depression, fatigue, and nausea. Implications for future studies are discussed.     

Design, recruitment and start up of a primary care weight loss trial targeting African American and Hispanic adults

Primary care offices are critical access points for obesity treatment, but evidence for approaches that can be implemented within these settings is limited. The Think Health! (?Vive Saludable!) Study was designed to assess the feasibility and effectiveness of a behavioral weight loss program, adapted from the Diabetes Prevention Program, for implementation in routine primary care. Recruitment of clinical sites targeted primary care practices serving African American and Hispanic adults. The randomized design compares (a) a moderate-intensity treatment consisting of primary care provider counseling plus additional counseling by an auxiliary staff member (i.e., lifestyle coach), with (b) a low-intensity, control treatment involving primary care provider counseling only. Treatment and follow up duration are 1 to 2 years. The primary outcome is weight change from baseline at 1 and 2 years post-randomization. Between November 2006 and January 2008, 14 primary care providers (13 physicians; 1 physician assistant) were recruited at five clinical sites. Patients were recruited between October 2007 and November 2008. A total of 412 patients were pre-screened, of whom 284 (68.9%) had baseline assessments and 261 were randomized, with the following characteristics: 65% African American; 16% Hispanic American; 84% female; mean (SD) age of 47.2 (11.7) years; mean (SD) BMI of 37.2(6.4) kg/m(2); 43.7% with high blood pressure; and 18.4% with diabetes. This study will provide insights into the potential utility of moderate-intensity lifestyle counseling delivered by motivated primary care clinicians and their staff. The study will have particular relevance to African Americans and women.