MEDICAL CARE
Volume 41, Number 4, pp 479–489
©2003 Lippincott Williams & Wilkins, Inc.
The Acceptability of Treatment for Depression Among
African-American, Hispanic, and White Primary Care Patients
LISA A. COOPER, MD, MPH,*† JUNIUS J. GONZALES, MD,‡ JOSEPH J. GALLO, MD, MPH,§
KATHRYN M. ROST, PHD,¶ LISA S. MEREDITH, PHD,储 LISA V. RUBENSTEIN, MD, MSPH,储#
NAE-YUH WANG, PHD,* AND DANIEL E. FORD, MD, MPH*†
BACKGROUND. Ethnic minority patients are
less likely than white patients to receive
guideline-concordant care for depression. It is
uncertain whether racial and ethnic differ-
ences exist in patient beliefs, attitudes, and
preferences for treatment.
METHODS. A telephone survey was con-
ducted 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 (adjust-
ed OR, 0.44; 95% CI, 0.26 – 0.76) had lower odds
than white persons of finding antidepressant
From the *Department of Medicine, School of Med-
icine, and the †Department of Health Policy and Man-
agement, Bloomberg School of Public Health, Johns
Hopkins University, Baltimore, Maryland.
‡From the National Institute of Mental Health, Rock-
ville, Maryland.
§From the Department of Family Medicine, Univer-
sity of Pennsylvania, Philadelphia, Pennsylvania.
¶From the Department of Family Medicine, Univer-
sity of Colorado Health Sciences Center, Denver,
Colorado.
储From RAND Health Program, Santa Monica,
California.
#From the Department of Medicine, VA Greater Los
Angeles Healthcare System and the Department of
Medicine, University of California at Los Angeles, Los
Angeles, California.
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 per-
sons. Some negative beliefs regarding treat-
ment were more prevalent among ethnic mi-
norities; 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 antidepres-
sant medication acceptable. Hispanics are less
likely to find antidepressant medication ac-
ceptable, and more likely to find counseling
acceptable than white persons. Racial and eth-
nic differences in beliefs about treatment mo-
dalities were found, but did not explain differ-
ences in the acceptability of depression
treatment. Clinicians should consider patients’
cultural and social context when negotiating
treatment decisions for depression. Future re-
Address correspondence and reprint requests to: Lisa
A. Cooper, MD, MPH, Welch Center for Prevention,
Epidemiology, and Clinical Research, 2024 East Monu-
ment Street, Suite 2-500, Baltimore, MD 21205-2223.
E-mail: lisa.cooper@jhmi.edu
Supported by the National Institute of Mental Health
R10 Cooperative Agreement Quality Improvement for
Depression (MH57992, MH5444, and MH5443), and the
John D. and Catherine T. MacArthur Foundation. Dr.
Cooper was a Fellow in the Robert Wood Johnson
Foundation Minority Medical Faculty Development Pro-
gram at the time this work was conducted.
Presented in part at the 12th International Confer-
ence on Mental Health Problems in the General Health
Care Sector, July 13–14, 1998, Baltimore, Maryland.
Received February 19, 2002; initial review April 11,
2002; accepted September 27, 2002.
479
COOPER ET AL
search should identify other attitudinal barri-
ers to depression care among ethnic minority
patients.
The primary care sector remains the most com-
mon site for delivery of depression care, particularly
for African Americans and Hispanics. In the 1980s,
studies showed that African Americans and Hispan-
ics utilized outpatient specialty mental health ser-
vices for psychiatric symptoms and disorders at
approximately half the rate of non-Hispanic white
persons.1– 6 Ethnic minority persons were not only
less likely to ever seek help in specialty mental health
settings, but also had higher rates of attrition from
follow-up visits. In general medical settings, how-
ever, ethnic minorities may be just as likely as white
persons to discuss mental health problems.7 In the
NIMH Epidemiologic Catchment Area Study, pa-
tients with major depression who reported receiving
care in general medical settings without also seeing a
specialist in mental health were more likely to be
African American than those receiving care in spe-
cialty mental health settings.8 Recent work shows
that use of outpatient services for mental health
problems has increased, particularly for African
Americans and Hispanics in general medical set-
tings.9,10 However, attrition from psychotherapy and
pharmacotherapy is higher, and rates of guideline-
concordant care remain lower, for ethnic minorities
compared with white persons.11–14
Important barriers to mental health care for
African American and Hispanic patients identified
in recent work include patient’s perceptions of
stigma, beliefs that life experiences are the cause of
depression, that problems should not be discussed
outside one’s family, mistrust of health care pro-
fessionals, and concerns about the effects of psy-
chotropic medication.15–17 It is unclear whether
use of spirituality, other active coping strategies,
informal sources of support like family and
friends, and help-seeking from clergy actually
serve as barriers to formal health care for ethnic
minority patients, but beliefs about religious or
supernatural causes of mental illness may lead to
lower mental health service use.17–19 Patient pref-
erences are likely to play an important role. Recent
work suggests that African Americans in primary
care settings prefer counseling over medications,
but perhaps without actually desiring referrals to
mental health specialists.20 –22
480
MEDICAL CARE
Key words: Depression; patient attitudes;
ethnic minorities; disparities; African Ameri-
cans; Hispanics (Med Care 2003;41:479 –489)
The objective of this study was to examine
whether racial and ethnic differences exist in pa-
tient attitudes toward depression care. We hypoth-
esized that African Americans and Hispanic pa-
tients would find antidepressant medication and
individual counseling for depression to be less
acceptable than white patients. We also hypothe-
sized that racial and ethnic differences in the
acceptability of depression treatment would be
partially explained by demographic factors (age,
gender, and education), illness factors (severity of
depression, functional status, disability days), past
treatment experience, and psychosocial factors
(social support and life events). Finally, we hy-
pothesized that racial differences in patient beliefs
about various aspects of treatment exist, and that
these differences would explain differences in the
acceptability of antidepressant medication and
counseling between ethnic minorities and white
persons.
Our conceptual framework is based on an ad-
aptation of the Theory of Reasoned Action, a value
expectancy model of decision-making.23 In value
expectancy models, behavioral intention and
eventual treatment-seeking are determined by a
person’s careful weighing of the potential benefits
and risks of the behavior (in this case, depression
treatment). Howland adapted the Theory of Rea-
soned Action to reflect the impact of “internal”and
“external” factors on behavior.24 Internal variables
are attitudes, beliefs, and social norms that may be
modifiable by education or experience. External
variables are characteristics and experiences that
either cannot be modified or can be changed only
with substantial effort (depression level, social
support). These external variables (eg, race, de-
pression level, treatment experience, social sup-
port) are distal determinants that affect intention
indirectly through the person’s attitudes (Fig. 1).
Materials and Methods
Study Design and Population
The data for this analysis were collected in the
baseline survey for randomized clinical trials of
Vol. 41, No. 4
FIG. 1. Relation of Patient Race, Ethnicity, and Other External Variables with Beliefs and Attitudes Regarding
Depression Treatment. Modified from The Theory of Reasoned Action (Azjen, 1996).
several quality improvement strategies for major
depression in primary care. The parent study was
approved by institutional review boards at each
participating institution. The data used in this
analysis are from three of the four separately
funded studies collectively referred to as the Qual-
ity Improvement for Depression or QID Project.
The QID includes the three NIMH-supported
studies designed to test different strategies for
implementing depression practice guidelines in a
variety of primary care settings and the Depression
Patient Outcomes Research Team (PORT) funded
by the Agency for Health care Research and
Quality (AHRQ). This study analyzes data from
the three NIMH-supported studies (The Hopkins
Quality Improvement for Depression [HQID]
Project, Mental Health Awareness Project
[MHAP], and the Quality Enhancement by Stra-
tegic Teaming [QuEST] Project) that used identical
questions to measure the main outcome variables
of interest in this paper. The QID study methods
have been described in detail elsewhere.25,26
Eligibility Criteria
Study subjects for this analysis are drawn from
919 patients (from HQID, MHAP, and QuEST)
who had visited their primary care physician
within 2 weeks of the baseline interview. The
ACCEPTABILITY OF DEPRESSION TREATMENT
overall enrollment response rate among identified
eligible patients across sites was approximately
83%. Patients were identified using a two-step
screening process in which patients had to: (1)
acknowledge having 1 week or more during the
past month when they felt sad, empty, depressed,
or lost interest in things they normally enjoyed,
and (2) meet criteria for major depressive episode
in the past year by the Composite International
Diagnostic Interview (CIDI).27 There were no dif-
ferences in first or second stage screening for
eligibility by ethnic minority status; participants
determined by screening to be eligible were more
likely to be female, minority, younger, and to have
more depression symptoms.26 Because there were
small numbers of Asian-American (n ⫽ 42) and
Native American patients (n ⫽ 48), we limited our
analyses to the 829 patients who self-identified
their race and ethnicity as African American, His-
panic, or non-Hispanic white.
Study Variables
Our variables were selected to describe the
characteristics of the study subjects and include
factors known to be predictors of depression treat-
ment and outcomes. Additionally, describing so-
cioeconomic status and other attitudinal and be-
havioral factors are important to determine
481
COOPER ET AL
whether ethnic group differences exist and to help
clinicians and health administrators determine the
external validity of our study findings. We selected
instruments that are generally relatively brief, have
been used successfully in primary care settings,
and have been shown to be reliable and valid in
African Americans and Hispanics. Variables for
these analyses are classified as external variables
(patient demographics, illness, treatment experi-
ence and visit variables, and psychosocial vari-
ables) and internal variables (beliefs and norms).
Demographic variables include patient age,
gender, race and ethnicity, marital status, and
education. Illness variables include depression se-
verity, measured by the modified Center for Epi-
demiologic Studies Depression scale (a 23-item
version of the standard CES-D that includes the
nine DSM criteria for major depression and ex-
cludes some of the standard items),28,29 functional
status measured by the MOS SF-12,30 number of
current chronic physical conditions (measured by a
checklist of 14 conditions), and self-reported dis-
ability days because of either physical health or
emotional problems within the past 4 weeks.
Treatment experience includes whether or not
the subject had any visits (in which emotional
problems were discussed) to general medical set-
tings or mental health settings in the past 6
months and whether or not the medications they
reported using in the preceding 6 months included
at least one antidepressant medication. Addition-
ally, patients were asked, “During your most re-
cent (primary care) visit, did a doctor or health
professional: (1) recommend that you go for coun-
seling to another doctor or therapist; (2) give you
a prescription for medication that would help with
your personal or emotional problems; or (3)
change medication that you were already taking
for your personal or emotional problems?”A pos-
itive response to at least one of these options was
considered to be indicative of emotional manage-
ment by the physician.
Psychosocial variables include social support
and life events. Major life events were measured
by asking patients whether they had experienced
each of 14 separate life events within the past 12
months. These events included change in marital
status, death of a loved one, serious illness or
injury, having a child, change in employment
status, financial or other family crises, and expo-
sure to violence. The total possible number of
events ranged from 0 to 14 and was categorized
into quartiles. The Medical Outcomes Study Social
482
MEDICAL CARE
Support Survey was used to measure tangible
support, affectionate interaction, positive social
interaction, and emotional or informational sup-
port.31 Social support scores were also divided into
quartiles.
Patient beliefs and norms regarding care for
depression, assessed in two of the three projects
(MHAP and HQID), have been described in pre-
vious work by Cooper et al32 and include perceived
need for treatment, perceived efficacy and con-
cerns about counseling and antidepressant medi-
cation, beliefs regarding the effects of spiritual/
religious beliefs and practices on depression,
preferences to see certain types of health profes-
sionals (same race or gender as the subject), and
perceptions of stigma. These items were devel-
oped based on data from focus groups with pa-
tients and a survey study to: (1) identify the range
of dimensions of treatment; (2) prioritize items to
be included in our final instrument; and (3) test
internal consistency and discriminant validity of
our items and scales.16,32 For the current study,
each belief was measured on a 5-point Likert scale
from strongly disagree to strongly agree. Re-
sponses were then dichotomized as strongly agree
or agree versus all other responses. The relations
of each item with patient ethnicity and with our
main outcomes were analyzed separately.
Main Outcome Variables
The main outcome variables were attitudinal
measures and included patient perceptions of the
acceptability of two treatment options: (1) taking
antidepressant medications and (2) going for in-
dividual counseling from a mental health profes-
sional. Patients were asked to rate these options
for helping themselves to feel better on a 4-point
Likert scale ranging from definitely acceptable to
definitely not acceptable. Responses to these items
were then dichotomized as acceptable versus not
acceptable
Analyses
All analyses were cross-sectional and based on
data from the baseline patient interview. We used
enrollment weights for each study site to increase
the similarity of the participating patient sample to
the sample of all eligible patients. To test our study
hypotheses, we first conducted bivariate analyses
Vol. 41, No. 4
of the acceptability of the two treatment options
by patient race. Second, we used logistic regres-
sion to examine the relations between patient race
and each of our main outcome variables: accept-
ability of medications and acceptability of individ-
ual counseling, adjusting simultaneously for pa-
tient demographic, illness, treatment experience,
psychosocial variables, and QID Project site. Third,
we analyzed the relations between patient race or
ethnicity and beliefs and social norms regarding
depression treatment. We then analyzed the rela-
tion of these beliefs and norms with the accept-
ability of depression treatment. Finally, we con-
ducted multivariate logistic regression models of
the acceptability of antidepressant medication and
counseling that adjusted for patient beliefs and
norms on a subset of our sample for which these
data were available (HQID and MHAP). We re-
peated all analyses using generalized estimating
equations (GEE) to account for the clustering of
patients by physician. Because the results from
GEE analyses were not significantly different from
the logistic regressions using weighted data, we
present the results of the logistic regression
analyses.
Results
Characteristics of Study Sample
Characteristics of the study sample are shown
in Table 1. There were 829 patients in the sample:
659 non-Hispanic white persons (335 from
MHAP, 294 from QuEST, and 30 from HQID), 97
African-American patients (36 from MHAP, 29
from QuEST, and 32 from HQID), and 73 Hispanic
patients (58 from MHAP, 10 from QuEST, and 5
from HQID). African Americans and Hispanics
were younger than white persons. A higher per-
centage of Hispanics were male than white per-
sons and African Americans. African Americans
were less likely to be married than white persons
and Hispanics. There were no ethnic differences in
educational status. There were also no ethnic
differences in number of chronic conditions, mean
CES-D-R score, mean mental health and physical
health scores on the SF12, and mean number of
disability days. With regard to treatment experi-
ence in the preceding 6 months, African Ameri-
cans and Hispanics were less likely than white
persons to report discussing emotional problems
in general medical settings and somewhat more
ACCEPTABILITY OF DEPRESSION TREATMENT
likely to report discussing emotional problems in
emergency room settings, but there were no racial
differences in discussing emotional problems in
specialty mental health settings. There were no
statistically significant ethnic differences in patient
reports of emotional management by primary care
physicians at their index visit or antidepressant
medication use in the past 6 months. There were a
higher percentage of African Americans than
white persons with social support in the lowest
quartile and life events in the highest quartile.
Relation of Patient Ethnicity with
Acceptability of Depression Treatments
Overall, 70% of patients (n ⫽ 579) found anti-
depressant medications to be an acceptable treat-
ment for depression (74% of white persons, 51%
of African Americans, 59% of Hispanics,
P ⬍0.001). After adjustment for all the confound-
ers identified in bivariate analyses, the odds of
finding antidepressant medication acceptable re-
mained significantly lower for African Americans
(OR, 0.30; 95% CI, 0.18 – 0.48) and Hispanics (OR,
0.44; 95% CI, 0.26 – 0.76) than for white persons
(Table 2).
Eighty-six percent of patients (n ⫽ 710) found
individual counseling to be an acceptable treat-
ment for depression (86% of white persons, 79%
of African Americans, 95% of Hispanics, P ⫽ 0.02).
After adjustment for confounders, the odds of
finding counseling acceptable for treatment of
depression remained somewhat lower for African
Americans (OR, 0.63; 95% CI, 0.35–1.12) and
significantly higher for Hispanics (OR, 3.26; 95%
CI, 1.08 –9.89) than for white persons.
Relation of Other External Patient Factors
with Acceptability of Depression
Treatments
Individuals who found antidepressant medica-
tions acceptable were younger, had more severe
depression (as measured by the modified CES-D)
and more disability (as measured by disability days
and the mental component of the SF-12) than
individuals who did not find medications accept-
able. These individuals also had a higher preva-
lence of previous treatment in general medical and
specialty mental health settings for their depres-
sion and were likely to have discussed an emo-
tional problem in their index primary care visit
483
COOPER ET AL MEDICAL CARE

TABLE 1. Characteristics of Patient Sample (%)

African
Total White American Hispanic P
(n ⫽ 829) (n ⫽ 659) (n ⫽ 97) (n ⫽ 73) value*

Demographic factors
Age 0.001
18–34 25 24 22 36
35–49 42 40 56 47
50–64 26 28 22 16
65⫹ 7 9 1 1
Gender 0.024
Male 27 27 20 38
Female 73 73 80 62
Education 0.193
Less than high school 11 10 11 19
High school graduate 31 31 30 26
Some college 37 36 41 40
College graduate 21 22 18 15
Marital status 0.004
Married 44 45 29 50
Separated/Divorced/Widowed 47 46 53 44
Never married 9 8 18 6
Illness measures (mean)
Depression level (CES-D-R score) 35.57 35.36 35.62 37.42 0.285
Mental component score, SF-12 30.11 30.14 30.57 29.22 0.007
Physical component score, SF-12 50.07 49.94 50.38 50.95 0.352
Number of medical comorbidities 1.95 1.97 1.82 1.81 0.043
Number of disability days in last 4 weeks 9.76 9.74 10.36 9.12 0.943
Treatment experience
Discussed emotional problem in GM setting 69 73 57 51 ⬍0.001
Discussed emotional problem in SMH setting 45 46 40 38 0.300
Discussed emotional problem in ER setting 9 8 14 11 0.075
Treatment by PCP at last visit 43 43 49 32 0.061
Took antidepressant medication in last 6 months 52 52 56 42 0.201
Social and behavioral measures
Social support quartile
1 (least support) 26 24 37 27 0.031
2 25 26 21 27
3 25 28 24 14
4 (most support) 24 23 19 32
Life events quartile 0.235
1 (0–2 events) 29 30 23 22
2 (3–4 events) 38 37 34 45
3 (5 events) 14 14 16 15
4 (6–11 events) 19 18 27 18
*P values from ␹2 tests for categorical variables and t tests for continuous variables.

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Vol. 41, No. 4 ACCEPTABILITY OF DEPRESSION TREATMENT

TABLE 2. Relation of Patient Race and Ethnicity with Acceptability of Treatment for Depression*
Model 1 Model 2 Model 3
Patient Unadjusted 95% P Adjusted P Adjusted 95% P
Patient Race n Odds Ratio CI value Odds Ratio Value Odds Ratio CI Value

Acceptability of
antidepressant
medication
White 659 1.00 ref 1.00 1.00 ref
African-American 97 0.38 0.24–0.59 ⬍0.001 0.36 ⬍0.001 0.30 0.19–0.48 ⬍0.001
Hispanic 73 0.53 0.32–0.88 0.014 0.51 0.011 0.44 0.26–0.76 0.003
Acceptability of
counseling
White 659 1.00 ref 1.00 1.00
African-American 97 0.64 0.37–1.10 0.106 0.73 0.326 0.63 0.35–1.12 0.119
Hispanic 73 3.16 1.10–9.07 0.033 2.46 0.102 3.26 1.08–9.89 0.037
*Acceptability of antidepressant medication and individual counseling are each measured on a 4-point scale and
dichotomized as acceptable versus not acceptable.
Model 1: Acceptability of treatment by patient race (unadjusted).
Model 2: Adjusted for patients’ age, gender, education, and QID study site.
Model 3: Adjusted for patients’ age, gender, education, QID study site, level of depression, mental health
functioning, specialty mental health treatment in last 6 months. The model for acceptability of antidepressant
medication also includes disability days in the last 4 weeks and receipt of antidepressant medication in last 6
months. The model for acceptability of counseling also includes life events in the past year.

than those who did not find medications accept-
able (data not shown).
Individuals who found individual counseling
acceptable were younger, more likely to be sepa-
rated, divorced, or widowed, had poorer function-
ing by the mental health component summary
score of the SF-12, were more likely to have had
previous treatment for depression in emergency
room or specialty mental health settings, more
likely to have discussed an emotional problem at
their index primary care visit, and more likely to
have life event scores in the two highest quartiles
than those who did not find counseling acceptable
(data not shown).
Relation of Patient Ethnicity With Beliefs
and Norms Regarding Depression Care
We were able to assess the relation of patient
ethnicity with beliefs and norms regarding depres-
sion care (other internal factors) in a subsample of
patients from two QID sites (HQID and MHAP).
In this subsample of 496 persons, there were
several ethnic differences in beliefs about depres-
sion care, shown in Table 3. African Americans and
Hispanics were more likely than white persons to
have negative beliefs about antidepressant medi-
cation. They were more likely to agree with the
statement, “Antidepressant medications are addic-
tive,” and less likely to agree with the statement,
“Antidepressant medications are effective.” Beliefs
about counseling were less consistent. For exam-
ple, although a higher percentage of African
Americans and Hispanics than white persons en-
dorsed the statement, “Counseling brings up too
many bad feelings like anger and sadness,”African
Americans and Hispanics were either just as likely
as or more likely than white persons to agree with
the statement, “For most people, counseling is as
effective as medication in treating depression.”
African Americans were more likely than white
persons and Hispanics to agree that, “Prayer can
heal depression” and to prefer to see a health
professional of their same race or ethnicity. There
were no ethnic differences in self-rated need for
treatment, perceptions of stigma, or preferences to
see a health professional of the same gender for
treatment of depression.
Patient beliefs and norms most strongly associ-
ated with acceptability of antidepressant medica-
tion and counseling were: perceptions of need for
treatment, effectiveness of antidepressant medica-

485
COOPER ET AL MEDICAL CARE

TABLE 3. Relation of Patient Race and Ethnicity with Beliefs and Social Norms Regarding Depression
Care in HQID and MHAP Sites
% Strongly Agree or Agree
African
Total White American Hispanic P
(n ⫽ 496) (n ⫽ 365) (n ⫽ 68) (n ⫽ 63) Value

I feel I need treatment for depression at this time. 68 68 70 68 0.808

Some medications are effective in treating 87 91 69 84 ⬍0.001
depression.
Antidepressant medications are usually addictive. 39 34 56 51 0.001
For most people, counseling is as effective as 54 50 57 74 0.003
medication in treating depression.
Counseling brings up too many bad feelings like 56 50 71 71 0.001
anger or sadness.
Prayer can help to heal depression. 70 67 93 67 ⬍0.001
I would be embarrassed if my friends knew I was 25 24 24 33 0.285
getting professional help for depression.
I would not want my employer to know I was 54 54 55 57 0.847
getting professional help for depression.
If I had depression, my family would be 17 16 15 22 0.523
disappointed in me.
I would prefer to see a health professional the same 35 35 34 40 0.724
gender as me.
I would prefer to see a health professional the same 15 14 25 13 0.053
race/ethnicity as me.

tion, effectiveness of counseling, and addictiveness
of antidepressant medications (data not shown).
Adjusting for these beliefs and norms in multi-
variate models using the HQID and MHAP sub-
sample did not narrow the gap in ethnic differ-
ences in the acceptability of antidepressant
medication (African Americans, adjusted OR, 0.26;
95% CI, 0.11– 0.65 and Hispanics adjusted OR,
0.38; 95% CI, 0.15– 0.97) or the acceptability of
counseling for African Americans (adjusted OR,
0.40; 95% CI, 0.10 –1.60). However, adjustment for
these beliefs appeared to attenuate ethnic differ-
ences in acceptability of counseling for Hispanics
(adjusted OR, 0.71; 95% CI, 0.14 –3.69).
Discussion
Both antidepressant medication and counseling
have been found to be effective treatment for
depression.33,34 Yet, primary care patient adher-
ence to each treatment modality remains less than
optimal. In this study, most depressed primary care
patients found either antidepressant medications
or counseling acceptable. However, the odds of
finding antidepressant medication acceptable
were lower for African Americans and Hispanics
compared with white persons. The odds of finding
counseling acceptable were somewhat lower for
African Americans, and higher for Hispanics, than
for white persons.
Our study also assessed patient beliefs and
norms; with these results, we can begin to under-
stand more about how African Americans and
Hispanics perceive the value and disadvantages of
various depression treatment options. African
Americans were least likely, and white persons
were most likely, to believe that medications are
effective in treating depression. African Americans
and Hispanics were more likely than white per-
sons to believe that antidepressant medications
are addictive, and counseling brings up bad feel-
ings. African Americans were more likely than
white persons and Hispanics to believe that prayer
can help to heal depression. African Americans
were also more likely than white persons and
Hispanics to state a preference for seeing a health
professional who belonged to their same race or
ethnicity. Although these beliefs and norms were
related to acceptability of both antidepressant
medication and counseling, with the exception of

486
Vol. 41, No. 4
the acceptability of counseling for Hispanics, they
did not generally explain ethnic and racial differ-
ences in the acceptability of antidepressant med-
ication or individual counseling for depression.
In general, our findings corroborate those of
earlier studies using community and primary care
patient samples. Previous studies have found that
African Americans indicate positive attitudes to-
ward help-seeking for mental health problems
and are similar to white persons in their percep-
tions of mental-illness associated stigma and need
for treatment.3,9,35 Recent work from the Partners
in Care (PIC) Study showed that most primary
care patients prefer counseling over medications
for treatment of depression, with African Ameri-
cans, but not Hispanics, having an even stronger
preference for counseling than white persons.20 In
contrast, we showed lower acceptability of antide-
pressant medication for both African Americans
and Hispanics, and higher acceptability of coun-
seling in Hispanics, compared with white persons.
Differences between our study results and those of
the PIC Study may be related to differences in
depression criteria and in the way patient prefer-
ences were assessed.
Attitudes, beliefs, and social norms are complex
phenomena that may not be captured using cate-
gorical responses on a structured questionnaire,
and understanding them in depth is critical to
targeting behavioral change. There is a large liter-
ature on attitudes and attitude change rooted in
the social psychology literature.36 Unfortunately,
the work to date in primary care has not fully
utilized theoretical frameworks or measurement
approaches from this behavioral science. For ex-
ample, one notion is that attitudes have an affec-
tive and a cognitive component, and that under-
standing the polarity of attitudes along these two
dimensions could certainly inform the develop-
ment and utility of interventions specifically tar-
geting those dimensions for attitude change, and
ultimately link it to behavior change. Furthermore,
attitudes are rooted in social relations, hence our
findings related to race and ethnicity, and theories
related to social identity and majority/minority
group influence may offer unique and valuable
contributions to this area of inquiry.37 Finally,
given our work related to depression, the roles of
mood and cognition in relation to attitudes cannot
be ignored.38 This translation of behavioral science
into applied research is a priority at the National
Institute of Mental Health.39
ACCEPTABILITY OF DEPRESSION TREATMENT
Other limitations of this study should be ac-
knowledged. First, because the study is cross-
sectional, no inferences can be drawn about cau-
sation. For example, we could not determine from
this study whether the beliefs endorsed preceded
treatment acceptability, or whether the beliefs and
preferences expressed led to differences in actual
treatment behavior. Second, the number of ethnic
minority patients was relatively small, and it is
possible that we lacked statistical power to dem-
onstrate significant ethnic differences in patient
preferences. Moreover, ethnicity groupings were
based on heterogeneous categories of African-
American, Hispanic, and white patients, and
Asian-American patients were not included.
Third, social, cultural, and economic variables such
as patients’ neighborhood characteristics, trust in
health professionals, explanatory models of illness,
and perceptions of the financial burdens related to
medications and counseling, were not measured
in this study and could further explain racial and
ethnic differences in acceptability of treatments.
Almost all the patients in this sample had health
insurance; this minimizes the likelihood of con-
founding of the relation of patient ethnicity with
preferences because of health insurance status.
Moreover, in separate analyses that included ad-
justment for patient income, our results were not
appreciably changed.
Our study contributes to the literature on pa-
tient attitudes toward depression care because
relatively few studies have explored the attitudes
of depressed ethnic minorities and white persons
toward specific attributes of depression
care.19,32,40,41 The strengths of our study include
the use of detailed clinical measures of depression
symptomatology, medical comorbidity, and func-
tional status; comprehensive measures of treat-
ment experience, life events and social support;
the use of validated, patient-centered measures of
attitudes toward depression care; and the study’s
inclusion of patients from a broad range of
community-based primary care settings across the
United States.
The ethnic disparity in acceptability of treat-
ment for depression remains poorly understood.
Although we identified differences in beliefs and
social norms for African Americans, Hispanics,
and white persons, these differences did not gen-
erally explain differences in acceptability of treat-
ment. Future studies should explore additional
attitudinal barriers to care such as trust in health
professionals, illness models, desire to participate
487
COOPER ET AL
in medical decision-making, and willingness to
use medical therapies for other conditions among
ethnic minorities. Notwithstanding these unan-
swered questions, potential implications of this
study are that clinicians managing ethnic minority
patients with depression should elicit patients’
explanatory models for depression and address
cultural and social perspectives (eg, their beliefs
about the benefits of spirituality, preferences for
culturally sensitive providers, desires to participate
in decisions and for family involvement in care,
and concerns about financial access) and com-
monly held negative perceptions of treatment
(addictiveness and lack of effectiveness of antide-
pressant medications, painful nature of counsel-
ing) that may serve as barriers to care. Previous
work shows that African Americans and other
ethnic minority patients have less participatory
visits with physicians than white patients.42 Pri-
mary care physicians might consider an initial trial
of watchful waiting that focuses on building inter-
personal rapport with their African-American and
Hispanic patients. If patients’ symptoms progress
or fail to remit during this time, using effective
communication skills and cultural sensitivity to
negotiate the initiation of active treatment may
eventually lead to higher patient acceptance of
treatment. Recent work suggests that although
quality improvement interventions that support
patient choice can improve the likelihood of pa-
tients receiving preferred treatments, patients pre-
ferring counseling over medication (such as Afri-
can Americans and Hispanics) may require
additional interventions to enhance entry into
treatment.43 Culturally tailored interventions that
incorporate culture-specific educational materials
and patient-centered approaches may help ad-
dress barriers to depression care among ethnic
minorities.
Acknowledgments
The authors thank Jose Arbelaez for his assistance
with statistical programming for this study.
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