Disclosure of Depression in Primary Care: A Qualitative Study of Women’s Perceptions

Published:August 13, 2016DOI:



      Health care providers are better able to diagnose depression and initiate treatment when patients disclose symptoms. However, many women are reluctant to disclose depressive symptoms. Little is known about the experience of disclosing depression symptoms in primary care among racially and ethnically diverse women across the life course. We qualitatively explore experiences of disclosure of depressive symptoms to primary care providers among self-identified African American, Hispanic and non-Hispanic White women.


      Twenty-four women with depression were recruited for open-ended interviews. We recorded, transcribed, and coded interviews using inductive content analysis.


      Two distinct domains emerged: participant factors that hinder and facilitate disclosure and provider cues that encourage and dissuade discussing depression. Participants described perceptions about primary care not being the appropriate place, fear of not having a choice in treatment decisions, and the emotional cost of retelling as impediments to disclosure; perceiving an increased likelihood of getting help was described as a facilitator. Women identified provider behaviors of asking about depression and showing concern as facilitators, and provider time constraints as a barrier to disclosure.


      Women perceive that primary care is not the appropriate place to disclose depression symptoms. Increased public education about behavioral health management in primary care, as well as more robust integration of the two, is needed. Efforts to improve depression disclosure in primary care must also encompass systematic use of depression screening tools and implementation of targeted interventions to cultivate provider empathy.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Women's Health Issues
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Adams J.R.
        • Drake R.E.
        • Wolford G.L.
        Shared decision-making preferences of people with severe mental illness.
        Psychiatric Services. 2007; 58: 1219-1221
        • Agency for Healthcare Research and Quality
        TeamSTEPPS®: Strategies and tools to enhance performance and patient safety.
        2016 (Available: Accessed: July 5, 2016)
        • Bell R.A.
        • Franks P.
        • Duberstein P.R.
        • Epstein R.M.
        • Feldman M.D.
        • Fernandez y Garcia E.
        • Kravitz R.L.
        Suffering in silence: Reasons for not disclosing depression in primary care.
        Annals of Family Medicine. 2011; 9: 439-446
        • Blozik E.
        • Scherer M.
        • Lacruz M.E.
        • Ladwig K.H.
        • KORA study group
        Diagnostic utility of a one-item question to screen for depressive disorders: Results from the KORA F3 study.
        BMC Family Practice. 2013; 14: 198
        • Cepoiu M.
        • McCusker J.
        • Cole M.G.
        • Sewitch M.
        • Belzile E.
        • Ciampi A.
        Recognition of depression by non-psychiatric physicians–A systematic literature review and meta-analysis.
        Journal of General Internal Medicine. 2008; 23: 25-36
        • Corson K.
        • Gerrity M.S.
        • Dobscha S.K.
        Screening for depression and suicidality in a VA primary care setting: 2 items are better than 1 item.
        American Journal of Managed Care. 2004; 10: 839-845
        • Deegan P.E.
        • Rapp C.
        • Holter M.
        • Riefer M.
        Best practices: A program to support shared decision making in an outpatient psychiatric medication clinic.
        Psychiatric Services. 2008; 59: 603-605
        • Dennis C.L.
        • Chung-Lee L.
        Postpartum depression help-seeking barriers and maternal treatment preferences: A qualitative systematic review.
        Birth. 2006; 33: 323-331
        • Elo S.
        • Kyngas H.
        The qualitative content analysis process.
        Journal of Advanced Nursing. 2008; 62: 107-115
        • Fernandez Y.G.E.
        • Franks P.
        • Jerant A.
        • Bell R.A.
        • Kravitz R.L.
        Depression treatment preferences of Hispanic individuals: Exploring the influence of ethnicity, language, and explanatory models.
        Journal of the American Board of Family Medicine. 2011; 24: 39-50
        • Goldman L.S.
        • Nielsen N.H.
        • Champion H.C.
        Awareness, diagnosis, and treatment of depression.
        Journal of General Internal Medicine. 1999; 14: 569-580
        • González H.M.
        • Vega W.A.
        • Williams D.R.
        • Tarraf W.
        • West B.T.
        • Neighbors H.W.
        Depression care in the United States: Too little for too few.
        Archives of General Psychiatry. 2010; 67: 37-46
        • Goodman J.H.
        Women's attitudes, preferences, and perceived barriers to treatment for perinatal depression.
        Birth. 2009; 36: 60-69
        • Hopkins K.
        • Sinsky C.A.
        Team-based care: Saving time and improving efficiency.
        Family Practice Management. 2014; 21: 23-29
        • Jesse D.E.
        • Dolbier C.L.
        • Blanchard A.
        Barriers to seeking help and treatment suggestions for prenatal depressive symptoms: Focus groups with rural low-income women.
        Issues in Mental Health Nursing. 2008; 29: 3-19
        • Keller A.O.
        • Gangnon R.
        • Witt W.P.
        The impact of patient–provider communication and language spoken on adequacy of depression treatment for U.S. Women.
        Health Communication. 2013; : 1-10
        • Kelm Z.
        • Womer J.
        • Walter J.K.
        • Feudtner C.
        Interventions to cultivate physician empathy: A systematic review.
        BMC Medical Education. 2014; 14: 219
        • Kravitz R.L.
        • Epstein R.M.
        • Feldman M.D.
        • Franz C.E.
        • Azari R.
        • Wilkes M.S.
        • Franks P.
        Influence of patients' requests for direct-to-consumer advertised antidepressants: A randomized controlled trial.
        JAMA. 2005; 293: 1995-2002
        • Kravitz R.L.
        • Paterniti D.A.
        • Epstein R.M.
        • Rochlen A.B.
        • Bell R.A.
        • Cipri C.
        • Duberstein P.
        Relational barriers to depression help-seeking in primary care.
        Patient Education and Counseling. 2011; 82: 207-213
        • Kroenke K.
        • Spitzer R.L.
        The PHQ-9: A new depression diagnostic and severity measure.
        Psychiatric Annals. 2002; 32: 509-515
        • Kroenke K.
        • Strine T.W.
        • Spitzer R.L.
        • Williams J.B.
        • Berry J.T.
        • Mokdad A.H.
        The PHQ-8 as a measure of current depression in the general population.
        Journal of Affective Disorders. 2009; 114: 163-173
        • Levinson W.
        • Gorawara-Bhat R.
        • Lamb J.
        A study of patient clues and physician responses in primary care and surgical settings.
        JAMA. 2000; 284: 1021-1027
        • Marcus S.C.
        • Olfson M.
        National trends in the treatment for depression from 1998 to 2007.
        Archives of General Psychiatry. 2010; 67: 1265-1273
        • Mulvaney-Day N.E.
        • Earl T.R.
        • Diaz-Linhart Y.
        • Alegria M.
        Preferences for relational style with mental health clinicians: A Qualitative comparison of African American, Latino and Non-Latino White patients.
        Journal of Clinical Psychology. 2011; 67: 31-44
        • National Institute for Health Care Management Foundation
        Identifying and treating maternal depression: Strategies & considerations for health plans.
        Author, Washington, DC2010
      1. NVivo qualitative data analysis software (Version 10). QSR International Pty Ltd, Burlington, MA2012
        • Pan A.
        • Sun Q.
        • Okereke O.I.
        • Rexrode K.M.
        • Hu F.B.
        Depression and risk of stroke morbidity and mortality: A meta-analysis and systematic review.
        JAMA. 2011; 306: 1241-1249
        • Raue P.J.
        • Schulberg H.C.
        • Heo M.
        • Klimstra S.
        • Bruce M.L.
        Patients' depression treatment preferences and initiation, adherence, and outcome: A randomized primary care study.
        Psychiatric Services. 2009; 60: 337-343
        • Robinson J.W.
        • Roter D.L.
        Psychosocial problem disclosure by primary care patients.
        Social Science and Medicine. 1999; 48: 1353-1362
        • Sentell T.
        • Shumway M.
        • Snowden L.
        Access to mental health treatment by English language proficiency and race/ethnicity.
        Journal of General Internal Medicine. 2007; 22: 289-293
        • Sleath B.
        • Rubin R.H.
        Gender, ethnicity, and physician-patient communication about depression and anxiety in primary care.
        Patient Education and Counseling. 2002; 48: 243-252
        • Song M.R.
        • Lee Y.S.
        • Baek J.D.
        • Miller M.
        Physical activity status in adults with depression in the National Health and Nutrition Examination Survey, 2005–2006.
        Public Health Nursing. 2012; 29: 208-217
        • Substance Abuse and Mental Health Services Administration
        The NSDUH Report: Major Depressive Episode and Treatment among Adults.
        Author, Rockville, MD2009
        • Triandis H.C.
        • Lisansky J.
        • Marin G.
        • Betancourt H.
        Simpatia as a cultural script of Hispanics.
        Journal of Personality and Social Psychology. 1984; 47: 1363-1375
        • Tucker C.M.
        • Herman K.C.
        • Pedersen T.R.
        • Higley B.
        • Montrichard M.
        • Ivery P.
        Cultural sensitivity in physician-patient relationships: Perspectives of an ethnically diverse sample of low-income primary care patients.
        Medical Care. 2003; 41: 859-870
        • Tylee A.
        • Freeling P.
        • Kerry S.
        • Burns T.
        How does the content of consultations affect the recognition by general practitioners of major depression in women?.
        British Journal of General Practice. 1995; 45: 575-578
      2. U.S. Preventive Services Task Force. Clinical Summary: Depression in adults: Screening. Available: Accessed: September 17, 2015.

        • Witt W.P.
        • Keller A.
        • Gottlieb C.
        • Litzelman K.
        • Hampton J.
        • Maguire J.
        • Hagen E.W.
        Access to adequate outpatient depression care for mothers in the USA: A nationally representative population-based study.
        Journal of Behavioral Health Services and Research. 2011; 38: 191-204
        • Young A.S.
        • Klap R.
        • Sherbourne C.D.
        • Wells K.B.
        The quality of care for depressive and anxiety disorders in the United States.
        Archives of General Psychiatry. 2001; 58: 55-61
        • Zhang J.
        • McKeown R.E.
        • Hussey J.R.
        • Thompson S.J.
        • Woods J.R.
        Gender differences in risk factors for attempted suicide among young adults: Findings from the Third National Health and Nutrition Examination Survey.
        Annals of Epidemiology. 2005; 15: 167-174


      Abiola O. Keller, PA-C, MPH, PhD, is an Assistant Professor at the College of Health Sciences at Marquette University. Her research focuses on improving women's health through studying patient–provider interactions and associated outcomes.


      Carmen R. Valdez, PhD, is an Associate Professor in the Department of Counseling Psychology at the University of Wisconsin-Madison. Her research examines the impact of family stress and sociocultural context on outcomes for Latino children.


      Rebecca J. Schwei, MPH, is an Assistant Researcher at the University of Wisconsin. Her research interests include health disparities, provision of linguistically appropriate health care, and the social determinants of health.


      Elizabeth A. Jacobs, MD, MPP, is a Professor of Medicine and Population Health Sciences at the University of Wisconsin-Madison. Her research interests include access to and cultural specificity of care, impact of interpreter service interventions on health care, and health literacy and numeracy.