2011 APA Gold Award: Culturally Sensitive Collaborative Treatment of Depression Among Chinese Americans in Primary Care
Asian-American immigrants rarely use psychiatric services, yet they are just as likely as other Americans to experience major depression. Frequently they lack the resources to seek help, encounter language barriers, and strongly stigmatize psychiatric illnesses. Together, these factors have contributed to underrecognition and undertreatment of mental illnesses, including depression, especially among less acculturated Asian immigrants.
At South Cove Community Health Center in Boston's Chinatown, a treatment model called Culturally Sensitive Collaborative Treatment (CSCT) has improved the recognition and treatment of major depression among its Chinese-American patients. For more than a decade, every patient at the clinic, an affiliate of Beth Israel Deaconess Medical Center and Children's Hospital, has been screened for depression by using a Chinese bilingual version of the Patient Health Questionnaire-9 (CB-PHQ-9). Patients who screen positive are contacted for further assessment with a culturally sensitive interview protocol that accommodates the beliefs and concerns of Chinese immigrants.
Patients who choose to enter treatment receive either usual care or care management, which includes regular telephone contact with a care manager and depression treatment by a primary care physician, psychologist, or psychiatrist. So far, the results have been very promising. Between 2004 and 2008, the treatment rate among depressed Chinese Americans at South Cove has increased by sevenfold, and the more recent addition of telepsychiatry promises to reach even more patients at the clinic's three satellite facilities. Staff at South Cove hope the program can serve as a model wherever members of racial-ethnic minority groups face practical and cultural barriers to treatment of mental disorders.
In recognition of its innovative program that promotes culturally sensitive treatment of major depression among Asian Americans in primary care, the CSCT program was selected to receive an APA Gold Achievement Award in the category of academically or institutionally sponsored programs. The winning program in the category of community-based programs is described on page 1384.
A new model for a pressing need
South Cove is a federally funded community health center in Boston serving predominantly immigrant Asian Americans. In 2010, it served more than 25,000 patients and provided more than 150,000 medical encounters and was the largest health provider for Asian Americans in Massachusetts. In 2008 alone, it served 12,000 Asian-American adults, primarily Chinese Americans. Most of its Chinese-American clientele are patients at South Cove's primary care clinic in Chinatown, which houses the behavioral health department, but the number of Asian-American immigrants at a satellite clinic in Quincy, about 20 miles away, has increased rapidly in recent years.
There are tremendous racial disparities in the treatment of depression. In particular there is a pressing need for improved recognition and treatment of depression among Chinese Americans. One study of an urban primary care setting in Boston estimated that up to 20% of underserved Chinese immigrants experience major depressive disorder. Such was the experience at South Cove. Most patients are Chinese Americans with financial, language, and cultural barriers to health care who lack familiarity with mental illness and face cultural stigma against psychiatric disorders.
When they are depressed, less acculturated Chinese immigrants tend to seek help from primary care physicians, lay people, and alternative medical practices and rarely utilize mental health services. Many of them have low mental health literacy and are unfamiliar with the concept of depression. Even when they do seek help, the primary care providers they encounter may lack the cultural sensitivity needed to detect depression and other mental disorders.
Faced with these challenges, in 2004, South Cove established CSCT, an innovative program designed to promote culturally sensitive care in a primary care setting. The program is based on a collaborative care model developed by Katon and others in 1995 for treating depression in primary care. In collaborative care, treatment of mental disorders is provided by a primary care physician with the support of a psychiatrist. Care managers provide intensive patient education and continued surveillance of adherence to medication regimens during depression treatment. Collaborative care has been shown to result in more favorable outcomes and improved satisfaction among patients with major depressive disorder.
CSCT builds on the collaborative care model by incorporating a cultural component. Implementation of the program began more than seven years ago with funding from the National Institute of Mental Health to develop culturally sensitive screening and assessment tools. The first step was to translate and validate a Chinese language version of the PHQ-9.
South Cove also developed an engagement interview protocol (EIP) to provide culturally sensitive interviews to patients. The EIP has two components—a standard psychiatric interview as well as a cultural component that explores patients' explanatory models of their illnesses by using Kleinman's eight questions on illness beliefs. With the knowledge of the patients' explanatory models of illness, the psychiatrist contextualizes depressive symptoms into a patient's physical health and social system and introduces information on depression in ways that are compatible with a patient's illness beliefs. The clinician can communicate about the illness in a way that is culturally cognizant and comprehensible in order to overcome cultural barriers. Together clinicians and patients can construct illness narratives that reframe the Western concept of depression into more culturally resonant forms.
CSCT in practice
Systematic depression screening and actively contacting depressed patients are integral parts of CSCT. Without them, most depressed Chinese-American patients would remain unrecognized in primary care clinics. Now, patients at South Cove are asked to complete the CB-PHQ-9 before annual physical visits. Patients who screen positive are contacted by a member of the mental health staff and informed of the results. They are asked to participate in a study of CSCT, which will involve culturally sensitive assessment and, if they choose, treatment at the center.
Patients who agree to further assessment complete an interview with a bilingual research psychiatrist using the EIP. Patients are asked to describe their symptoms, their opinions about what caused the symptoms, how the symptoms affected their daily lives, and what they hoped that treatment would accomplish. Based on the participants' answers, the clinicians are able to communicate information about depression in more comprehensible ways by using the participants' language and illness beliefs.
After the psychiatric assessment, patients with confirmed major depressive disorder are encouraged to seek treatment for their depression from their primary care physicians, who receive a letter about the patient's diagnosis and a recommended treatment plan. At that point, patients may choose to seek treatment or consultation from a psychiatrist or a therapist at the center.
Patients who agree to receive treatment for depression are assigned by random to usual care or care management, a telephone-based intervention provided by care managers. All patients who enter CSCT are assessed by blinded assessors 1.5, 3.5, and six months later with the 17-item Hamilton Rating Scale for Depression (HAM-D-17) and the Clinical Global Impression Scale (CGI).
Staff of the program include primary care physicians, psychiatrists who interview patients by using the EIP and provide consultations to primary care physicians, nursing staff who perform the depression screenings, care managers who treat patients assigned to care management, and research coordinators who perform the blind assessments with the HAM-D-17 and the CGI. The director of CSCT, a bilingual and bicultural psychiatrist on staff at South Cove, is on the faculty of the Department of Psychiatry at Massachusetts General Hospital.
Outcomes and effectiveness
A study of the program indicates that the CSCT model significantly improved the recognition and treatment of major depression in a typically underserved group. Between 2004 and 2007, a total of 4,228 Chinese-American patients receiving primary care at South Cove were screened for depression. A total of 296 (7%) screened positive, and they were contacted within two weeks to inform them of their results and to recommend that they receive more focused psychiatric assessment. At that point, they were invited to be part of a study of CSCT.
More than half of patients declined further treatment, but 122 patients agreed to pursue additional assessment by a clinician using the EIP. Of the 104 participants whose depression diagnosis was confirmed by the assessment, 100 (96%) agreed to enter treatment. Overall 43% of South Cove's Chinese-American patients who had a positive depression screen entered treatment, significantly higher than the percentage (6.5%) of patients who screened positive for depression and sought treatment before the study began.
Patients who agreed to seek treatment for depression were assigned by random with a computer-generated table to receive care management by telephone (N=55) or usual care (N=45) for 24 weeks. Patients in both groups were encouraged to discuss depression treatment with their primary care physicians. Treatment response by both groups compared favorably with results of several large-scale depression studies, including the STAR*D study, although there were no significant differences between the care management and usual care groups in response rates (60% versus 50%) or in remission rates (48% versus 37%).
CSCT has proven to be a promising way to recognize and treat major depression in an ethnic minority population that highly underutilizes mental health services. In the process, it has served as a powerful tool for educating the Chinese community about depression. Many patients report that depression screening has introduced the concept of depression as an illness. It has helped to make those with high scores on screening assessments more aware of their symptoms and prompted them to seek help. Some patients have shown the CB-PHQ-9 to family members who manifest symptoms of depression as a way to encourage them to seek help.
Obstacles overcome and future expansion
The CSCT program has overcome many obstacles, not least of which is the challenge of implementing systematic depression screening in a population that is unfamiliar with and tends to stigmatize mental illness. For the last ten years, completion of the bilingual health questionnaire has been part of routine primary care at the heath center, despite a high volume of patients at its busy clinics. Systematic screening for depression would not be possible without buy-in from primary care physicians and the assistance of primary care nursing staff.
Funding for the program is secure through 2013, an impressive accomplishment in light of the highly competitive environment for research funding. The program was developed through a five-year grant of $756,093 from the National Institute of Mental Health beginning in 2003. Its success led NIMH to fund a second phase called Telepsychiatry-Based CSCT (T-CSCT) with a grant of approximately $1.8 million. The T-CSCT program will extend the reach of CSCT by using videoconferencing technology to provide culturally sensitive psychiatric assessment to depressed Chinese Americans at South Cove's satellite clinics. Videoconferencing equipment installed at South Cove's primary care clinics is connected to the networks at Massachusetts General Hospital.
Since 2008, the T-CSCT program has screened 17,477 patients at one of South Cove's primary care clinics. Interim data analyses conducted this past March showed that depressed Chinese-American patients who participated in T-CSCT had better outcomes than those who received usual care. Telepsychiatry was well received by Chinese Americans, and South Cove staff have shared their experience and evidence with staff of different centers in Massachusetts that are interested in adopting its use. In addition, by training mental health professionals in other states in the use of telepsychiatry technology, South Cove staff hope CSCT will be offered at clinics serving racial-ethnic minority populations across the country.
A way forward
At South Cove Community Health Center, CSCT has helped to challenge cultural stigmatization against mental illness among Chinese-American patients and address persistent disparities in treatment of mental disorders in an ethnic minority. Systematic screening and assessment with culturally specific instruments is credited with a sevenfold increase in utilization of psychiatric services among depressed Chinese Americans in the center's primary care setting. Chinese-American patients have learned to recognize symptoms of depression in the context of their unique culture and to help their family members do the same. Perhaps even more encouraging, the key components of CSCT—systematic depression screening, follow-up assessment with culturally sensitive techniques, and primary care treatment with care management by telephone—appear to be readily adaptable to any setting that treats patients in underserved minority groups.
For more information, contact Albert Yeung, M.D., Sc.D., Program Director, CSCT, Behavioral Health Department, South Cove Community Health Center, 145 South St., Boston, MA 02111 (e-mail: ayeung@partners.
