In 2004 the FDA issued a box warning that raised concerns about increased suicidal ideation in youths taking antidepressants. A study in Health Services Research by associate professor of psychiatry Benjamin L. Cook, PhD, MPH, research scientist Ye Wang, PhD, MA, postdoctoral research fellow at USC Rajan Sonik PhD, JD, MPH, professor of public health (health policy) at Yale Susan Busch, PhD, assistant professor of psychiatry Nicholas Carson, MD, instructor in psychiatry Ana M. Progovac, PhD, and Daniel C. Tosteson Professor of Health Care Policy (Statistics) Alan M. Zaslavsky, PhD discovered that after this warning antidepressant use decreased for White youth, but increased for Black and Latino youths.

Unlike most previous studies, this research tracked the response to the “black box” warning at the level of the individual provider as well as at the more aggregated group levels more commonly considered.  This analytic approach revealed the importance of provider-level variation in disparities in treatment. Black and Latino children are subject to de facto segregation, being largely served by a distinct set of clinicians from those serving white children.  The study found that it takes longer for new safety guidelines to be adopted by the clinicians who serve patients from racial/ethnic minority groups. This means that care of these patients is less likely to be influenced by new scientific evidence that could affect their medical treatment. 

Furthermore, patients from racial/ethnic minority groups are less likely than Whites to seek out a mental health specialist when dealing with anxiety and depression, more often addressing the issues with their primary care physicians who generally have less specialized knowledge than mental health specialists. Racial/ethnic minorities also tend to receive mental health information from different sources than Whites, and are less likely to trust the information that they receive.

Paradoxically, the net effect of lesser response to the black-box warning among minority-serving clinicians is not clear.  The decline in use of antidepressants following the warning tended to close a long-standing racial/ethnic disparity in antidepressant use, but may have led to denial of these medications to patients for whom their benefits outweighed the risks, especially among White patients who were most responsive to the new recommendations. 

Nonetheless the systematic differences in flow of information revealed by this study are likely to negatively affect quality of care for minorities when crucial information is differentially disseminated.  Cook, Zaslavsky and colleagues suggest that policy makers should heed the importance of dissemination of risk warnings and other changing clinical guidelines, and consider interventions that specifically reach out to the outpatient facilities and community health centers that predominantly serve racial/ethnic minority groups when new medical information is released.