Williams et al they desire much more information than they tend to receive (Waitzkin 1984). Focused, empathic communication can bridge these gaps, as physicians become aware of communi- cation challenges and seek to increase concordance between their perceptions, concerns, and preferences and those of their patients (Willems et al 2005a). Psychosocial issues The physician-older patient relationship can be strongly affected by patients’ psychosocial challenges. Patients depend upon their physicians to respond to their psychosocial needs and concerns (Katon et al 2004; Neumeyer-Gromen et al 2004). In response, physicians must approach their patients with models of care that go beyond the biomedical, to biopsychosocial approaches that effectively treat the whole patient. Many primary care physicians face impressive challenges in diagnosing and treating depression in their elderly patients (Schulberg et al 1999; Katon et al 2004; Neumeyer-Gromen et al 2004). Older patients tend to be more hesitant than younger patients to bring up issues of a psychosocial nature in their primary care visits and they tend to underreport depressive symptoms (Greene et al 1987; Lyness et al 1995). Failure to recognize depression is a common occurrence in the elderly, especially when there are comorbid medical conditions that complicate the patients’ experience of illness (Katon and Sullivan 1990; Badger et al 1994; Carney and Freedland 2003). Older patients may not recognize their experience of a mood disorder and may attribute depressive symptoms to somatic causes that they can more easily deﬁne (Lyness et al 1995). Patients’ underreporting of depressive symptoms can be further affected by their cultural back- ground, generational status, ethnicity, and socio-economic status. The most physically, economically, socially, and emotionally vulnerable older adults tend to be at the greatest risk for underreporting of psychosocial issues in the primary care interaction (Good et al 1987; Lyness et al 1995; Borowsky 2000; Croghan et al 2003). Many older patients avoid discussion of psychosocial issues because they are concerned with being “a good patient”—one who does not show any negative or depressed feelings to their physicians (Wittink et al 2006). Many older patients grew up in an era of the paternalistic physician- patient relationship, and are reluctant to accept partnerships in care, even when their physicians encourage reciprocity and joint decision-making. Older patients may be deferent and respectful, and remain relatively passive, even though they have important concerns and psychosocial needs that must 460 be addressed by their physicians in order to insure positive health care outcomes such as satisfaction, adherence, and health (Wittink et al 2006). Physicians’ awareness of their own communication behaviors can, of course, do much to improve care for their older patients. In the presence of the many biomedical challenges of aging, physicians may be tempted to raise fewer psychosocial issues with their older patients than with their younger patients (Greene et al 1987) and respond more positively to psychosocial concerns in the young than in the old (Greene et al 1987). Discussions tend to be primarily biomedical in nature and often little attention is given to psychosocial talk with elderly patients, perhaps because of a potential belief that the prognosis for older patients’ psychosocial problems is poor (German et al 1987). The more that physicians discuss, ask questions, counsel, and give patients information on psychosocial topics, however, the more satisﬁed their patients are and the more opportunities become available to solve some of the difﬁculties that contribute to elder patients’ distress (Bertakis et al 1991). It is vitally important for physicians to be aware of potential depression in their older patients. Primary care physicians are often the ﬁrst and only providers of mental health services to many older patients (Lyness et al 1995; Wittink et al 2006). Under-recognition of elder depression can lead to serious consequences such as nonadherence and poor outcomes in the management of multiple chronic diseases, and even result in increased risk of suicide (Coe et al 1984; Carney et al 1994; Conwell 1994; DiMat- teo et al 2000). Physicians’ lack of awareness of patient depression can undermine their patients’ trust as well as their rapport with patients. Such limitations in understand- ing between physician and patient can lead to nonadherence, dissatisfaction, inaccuracy of diagnosis, poor patient health perceptions, and even more doctor-shopping by patients (DiMatteo and DiNicola 1982; Hall et al 1988; Stewart 1995; Tickle-Degnen 2003; Jahng et al 2005). Research suggests many ways in which physicians can enhance their communication with older patients and improve their chances of detecting, and helping to care for, patients’ depression. When physicians display empathy toward their patients, ask questions about social and emotional content, solicit patient feedback, and employ active listening, their patients tend to be more willing to share their concerns (Hall et al 1988; Roter et al 1997). Additional research is needed to further investigate the precise determinants, outcomes, and nature of physician-older patient communication about Clinical Interventions in Aging 2007:2(3)