Investigating the influence of African American and African Caribbean race on primary care doctors' decision making about depression

A Adams,L Vail,C.D Buckingham,J Kidd,S Weich,D Roter

doi:10.1016/j.socscimed.2014.07.004

A Adams, L Vail + Show 4 more

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https://doi.org/10.1016/j.socscimed.2014.07.004

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Abstract

This paper explores differences in how primary care doctors process the clinical presentation of depression by African American and African-Caribbean patients compared with white patients in the US and the UK. The aim is to gain a better understanding of possible pathways by which racial disparities arise in depression care. One hundred and eight doctors described their thought processes after viewing video recorded simulated patients presenting with identical symptoms strongly suggestive of depression. These descriptions were analysed using the CliniClass system, which captures information about micro-components of clinical decision making and permits a systematic, structured and detailed analysis of how doctors arrive at diagnostic, intervention and management decisions. Video recordings of actors portraying black (both African American and African-Caribbean) and white (both White American and White British) male and female patients (aged 55 years and 75 years) were presented to doctors randomly selected from the Massachusetts Medical Society list and from Surrey/South West London and West Midlands National Health Service lists, stratified by country (US v.UK), gender, and years of clinical experience (less v. very experienced). Findings demonstrated little evidence of bias affecting doctors' decision making processes, with the exception of less attention being paid to the potential outcomes associated with different treatment options for African American compared with White American patients in the US. Instead, findings suggest greater clinical uncertainty in diagnosing depression amongst black compared with white patients, particularly in the UK. This was evident in more potential diagnoses. There was also a tendency for doctors in both countries to focus more on black patients' physical rather than psychological symptoms and to identify endocrine problems, most often diabetes, as a presenting complaint for them. This suggests that doctors in both countries have a less well developed mental model of depression for black compared with white patients.

Highlights

Previous research has demonstrated variation in the ability of different ethnic groups to access appropriate care for depression (Das et al, 2006), and subsequently in the quality of care they experience (Simpson et al, 2007; Gonzalez et al, 2010)
Research shows that African-Caribbeans are or more likely to suffer from depression, often mixed with anxiety, than White British people (Nazroo, 1997; Shaw et al, 1999; Weich and McManus, 2002), findings about the prevalence of depression amongst African Americans compared with White Americans are inconclusive (Riolo et al, 2005; Williams et al, 2007)
The current study contributes a detailed analysis of British and American primary care doctors' cognitive and decision making processes when evaluating racially diverse simulated patients presenting with symptoms strongly suggestive of depression

Summary

Introduction

Previous research has demonstrated variation in the ability of different ethnic groups to access appropriate care for depression (Das et al, 2006), and subsequently in the quality of care they experience (Simpson et al, 2007; Gonzalez et al, 2010). In terms of cultural social exclusion, African Caribbeans' distinctive speech, language and gestures can lead to misunderstanding and fear amongst predominantly white clinicians (General Medical Council, 2014), so that they attract labels such as ‘big, black, bad, mad and dangerous’ (McLean et al, 2003; Keating, 2007). They experience more control and restraint procedures within secondary mental health services, which act as agents of social control (McLean et al, 2003). Cultural differences in the conceptualisation of depression and in people's help-seeking behaviours aside, previous research suggests that in the UK African-Caribbeans are less likely than White patients to receive a diagnosis of depression from their general practitioner (Lloyd, 1993; Odell et al, 1997), and this is the case in the US for African-Americans and white patients (Borowsky et al, 2000; Miranda and Cooper, 2004; Simpson et al, 2007; Trinh et al, 2011; Lukachko and Olfson, 2012)

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