A study of a culturally focused psychiatric consultation service for Asian American and Latino American primary care patients with depression

A study of a culturally focused psychiatric consultation service for Asian American and Latino American primary care patients with depression
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  STUDY PROTOCOL Open Access A study of a culturally focused psychiatricconsultation service for Asian American and LatinoAmerican primary care patients with depression Nhi-Ha T Trinh 1* † , C A Bedoya 2 † , Trina E Chang 1 , Katherine Flaherty 3 , Maurizio Fava 1 and Albert Yeung 1 Abstract Background:  Ethnic minorities with depression are more likely to seek mental health care through primary careproviders (PCPs) than mental health specialists. However, both provider and patient-specific challenges exist. PCP-specific challenges include unfamiliarity with depressive symptom profiles in diverse patient populations, limitedtime to address mental health, and limited referral options for mental health care. Patient-specific challengesinclude stigma around mental health issues and reluctance to seek mental health treatment. To address theseissues, we implemented a multi-component intervention for Asian American and Latino American primary carepatients with depression at Massachusetts General Hospital (MGH). Methods/Design:  We propose a randomized controlled trial to evaluate a culturally appropriate intervention toimprove the diagnosis and treatment of depression in our target population. Our goals are to facilitate a) primarycare providers ’  ability to provide appropriate, culturally informed care of depression, and b) patients ’  knowledge of and resources for receiving treatment for depression. Our two-year long intervention targets Asian American andLatino American adult (18 years of age or older) primary care patients at MGH screening positive for symptoms of depression. All eligible patients in the intervention arm of the study who screen positive will be offered a culturallyfocused psychiatric (CFP) consultation. Patients will meet with a study clinician and receive toolkits that includepsychoeducational booklets, worksheets and community resources. Within two weeks of the initial consultation,patients will attend a follow-up visit with the CFP clinicians. Primary outcomes will determine the feasibility andcost associated with implementation of the service, and evaluate patient and provider satisfaction with the CFPservice. Exploratory aims will describe the study population at screening, recruitment, and enrollment and identifywhich variables influenced patient participation in the program. Discussion:  The study involves an innovative yet practical intervention that builds on existing resources and strivesto improve quality of care for depression for minorities. Additionally, it complements the current movement inpsychiatry to enhance the treatment of depression in primary care settings. If found beneficial, the intervention willserve as a model for care of Asian American and Latino American patients. Trial Registration: NCT01239407 Background The project proposes a randomized controlled trial toevaluate a culturally focused intervention to improve therecognition and treatment of depression in Asian Amer-ican and Latino American primary care patients atMassachusetts General Hospital (MGH). The interven-tion entails using multi-lingual consultations and toolk-its, for providers and patients, over the course of two visits. Goals of the project are to facilitate a) primary care providers ’  ability to provide appropriate, culturally informed care of depression in adult Asian Americanand Latino American patients, and b) patients ’  knowl-edge of and resources for receiving treatment fordepression. * Correspondence: †  Contributed equally 1 Depression and Clinical Research Program, Massachusetts General Hospital,One Bowdoin Square, sixth floor Boston, MA 02114, USAFull list of author information is available at the end of the article  Trinh  et al  .  BMC Psychiatry   2011,  11 :166 © 2011 Trinh et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (, which permits unrestricted use, distribution, and reproduction inany medium, provided the srcinal work is properly cited.  This intervention focuses on the primary care setting,as ethnic minorities with depression are much morelikely to be cared for by primary care physicians (PCPs)than by specialists in mental health [1]. Targeting boththe provider and patient in the intervention is impor-tant for a variety of reasons. Providers may face chal-lenges in correctly diagnosing depression in patientswhose ethnic background is different from their own,due to difficulties in correctly identifying depressivesymptoms or using different cues or vocabulary todescribe depression [2,3]. In addition, there may be some variation in symptom presentations. For example,Latino Americans may give greater emphasis to somaticcomplaints than non-Latino Caucasians [4], and asAsian Americans become more acculturated, they tendto report worsening levels of mood symptoms [5].These varying symptom presentations can differ fromwhat most clinicians are trained to expect, resulting inclinical misdiagnoses [6]. Patients themselves are reluc-tant to seek treatment; Asian Americans may experiencehigher levels of perceived stigma related to seekingmental health treatment, particularly from their families[7]. In addition, Latino Americans may have had fewerhelpful mental health treatment experiences than non-Latino Caucasians, which may make them less willingto seek treatment in the future [8].As one solution to bridge this gap between providerknowledge and patient needs, Kirmayer et al. developedthe Cultural Consultation Service (CCS) model in 1999[9,10]. The CCS responded to requests for assistance placed by primary care providers and mental health pro-fessionals facing difficulties with the assessment or treat-ment of ethnically diverse patients. In their evaluation of 100 cases referred to the CCS, Kirmayer ’ s group foundthat cultural misunderstandings were associated with anincreased risk for incomplete assessments, incorrectdiagnoses, and inadequate or inappropriate treatment.By providing cultural consultations and formulationsbased on the DSM-IV cultural formulation model, theCCS effectively improved diagnostic assessment andtreatment for their diverse population [9].In a critical review of the literature, Van Voorhees etal evaluated interventions attempting to reduce dispari-ties between non-Latino Caucasians and ethnic minori-ties and found that multi-component interventions weresuccessful in improving depressive symptoms and func-tional status in nearly every study [11]. These interven-tions utilized a chronic disease management model,complete with case management, enhancement of accessto care, and a variety of approaches tailored to the spe-cific system, provider, and patient factors. One study,the  “ Improving Mood-Promoting Access to Collabora-tive Treatment ”  (IMPACT), not only improved all out-comes, but also eliminated ethnic disparities [12]. Thistrial randomized older adults with depression to usualcare or to an intervention including case management,patient education, and either medication or problem-sol- ving psychotherapy within a collaborative care modelincluding available psychiatric consultation. The inter- vention demonstrated a reduction of depressed mood by at least 50 percent as compared to usual care; however,there was little cultural tailoring of the materials, i.e.,the  “ matching of study intervention goals and materialsto the needs and sensitivities of specific populations. ”  Infact, Van Voorhees et al concluded that none of the stu-dies in their review compared culturally tailored inter- ventions with standard interventions in a randomizedcontrol trial. They also wondered if   “ structural changesin the pattern of delivery of mental health services ”  and “ culturally tailored mental health service programs ”  may prove to be particularly effective to minorities impactedby mental health issues [11]. The proposed interventionseeks to provide such a model to Asian American andLatino American primary care patients - understudiedpopulations in health care disparities interventionresearch [13,14]. Preliminary Studies The first part of the proposed intervention, conductingclinic-wide screening for depression, builds on the workby Dr. Albert Yeung. In one project using widespreaddepression screening in an Asian American populationin primary care in 2004-2005, Yeung and colleagues [15]used a Chinese bilingual version of the Patient HealthQuestionnaire (CB-PHQ-9) to screen and identify patients with possible depression. Patients who screenedpositive were interviewed to establish psychiatric diagno-sis and to engage them in treatment. Their workdemonstrated that depression could be identified in thissample of primary care patients, using a translatedscreening questionnaire and a culturally sensitive clinicalevaluation to engage patients in mental health treat-ment. In addition, 44% of those who screened positiveagreed to come in to be assessed by a psychiatrist;among those who were then diagnosed with MDD, 93%were willing to accept treatment. These findings demon-strate that screening minority patients in primary caresettings can be both a feasible and effective tool to iden-tify patients likely to have clinical depression.Mischoulon et al. reported that screening in primary care settings may not be enough; independent screeningby psychiatrists in primary care settings may not be ade-quate to ensure appropriate management of depressionby PCPs [16]. In this study, patients were screened forMDD in a community-based primary care health center.For those who met criteria for MDD, a letter was mailedto their PCP informing them of their patient ’ s diagnosisof MDD. Forty outpatients, of whom 29 (72 percent)  Trinh  et al  .  BMC Psychiatry   2011,  11 :166 2 of 10  were Latino American, were found to meet criteria forMDD. Medical record charts were reviewed 3 monthslater to determine the PCPs ’  management following thediagnosis. Of the 38 patients who remained in the study at 3 months, 20 (53 percent) received no interventionfor depression from the PCP, and of these, 14 (70 per-cent) were Latino American. Only five (13 percent) wereprescribed an antidepressant by their PCP, nine (24 per-cent) were referred to mental health services for medica-tion, psychotherapy or combination treatment, and four(11 percent) were prescribed an antidepressant and thenreferred to mental health services. Mischoulon and col-leagues concluded that possible explanations for thislack of treatment of depression may include time con-straints during primary care visits, patient and/or physi-cian reticence, and insufficient education of PCPs aboutclinical depression. These findings suggest that screen-ing and notification must be supplemented by additionalinterventions if they are to have an impact on the careof depression.The second part of this proposed intervention derivesfrom a pilot project from our group that applied a cul-turally focused psychiatric consultation service for agroup of high service-utilization patients. In the initialpilot, the service was based on the Cultural ConsultationService (CCS) model developed by Kirmayer et al [9,10]. As part of the consultation service, members of the pro- ject team met monthly with case managers who werefollowing a group of chronically, medically ill patients.Cases with difficult psychiatric issues were discussed,and formal consults could be requested for patientswhose presentation and treatment was complicated by cultural issues. Members of the consultation service alsomet regularly to discuss cases. Results of the initialneeds assessment indicated that case managers per-ceived a strong need for such a culturally focused psy-chiatric consultation service, but tended to refer patientsfor psychosocial issues rather than for psychiatric diag-nostic assessment. Similarly, in a six-month follow-up tothe culturally focused psychiatric clinical intervention,case managers were asked about their overall perceptionof the utility of the service and obstacles to its use.Based on their responses, case managers perceived a sig-nificant value, but tended to underutilize the service.This experience suggested four hypotheses. The consul-tation service would benefit from: a) focusing on a spe-cific psychiatric diagnosis; b) targeting patients at theirprimary care providers ’  offices directly, providing agreater ability to connect with minority patients than anintervention that serves as a liaison to staff; c) makingthe consultation service more user-friendly; and d)enriching the intervention with patient-focused materi-als, in order to maximize patient knowledge and skills.These findings further supported the recruitment of patients through screening for those who meet criteriafor likely depression, rather than relying solely on refer-rals by PCPs.A final component of the CFP intervention was basedon the team ’ s experience with adapting cognitive beha- vioral interventions for the treatment of depressive dis-orders in chronically ill Latino Americans [17,18]. For example, in a sample of HIV-positive foreign-bornLatino Americans, a cognitive behavioral interventionwas linguistically/culturally adapted and administered by bilingual/bicultural staff. Participants received either a10-week cognitive behavioral stress management(CBSM) intervention or a one-day seminar. Results indi-cated that, compared to those who only received theseminar, participants who received the CBSM interven-tion reported significantly less anger, maladaptive cop-ing, and HIV-related symptoms [19]. These results ledto recommendations for including culturally-adaptedcognitive behavioral therapy techniques within clinicalinterventions for chronically-ill Latinos, for example, by addressing cultural factors such as familismo andrespeto. Study Aims This study is a randomized controlled trial of a cultu-rally focused psychiatric consultation model for AsianAmerican and Latino American primary care patientswith depression (see Figure 1). The  primary aim  of thestudy is to determine the feasibility, satisfaction and costassociated with implementing a CFP consultation servicewithin a primary care setting at MGH. Additionally, an exploratory aim  serves to describe (e.g., demographicfactors; level of depression; service utilization) the parti-cipant patient population at screening, recruitment andenrollment, as well as to determine which, if any, of these variables influence participation in the study (e.g.,consent to be contacted). Methods/Design Overview This is a randomized controlled trial of the CFP inter- vention. During the study period, all patients in partici-pating primary care clinics will receive a screening formfor symptoms of depression; data on age, gender, race,ethnicity and primary language will be obtained at thetime of screening. Asian American and Latino Americanpatients who screen positive for clinical depression willbe contacted by study staff and invited to participate inthe CFP study. Eligible patients will be randomizedeither to the intervention arm or usual care based ontheir primary care provider. Patients in the interventionarm will receive the CFP intervention over two visitsand then called at six-months by study staff to adminis-ter follow-up questionnaires (described below). Patients  Trinh  et al  .  BMC Psychiatry   2011,  11 :166 3 of 10  in the usual care arm will be called at baseline and atsix-month follow-up by study staff to administer ques-tionnaires (described below). To evaluate the culturalcomponents of the study, a number of qualitative inter- views will also be conducted with participants in theintervention and usual care arms, and with members of the target population who did not participate in thestudy. Please see Figure 1 for the study flowchart. Description of Intervention The CFP intervention includes two major components:1) Patients receiving the intervention will undergo aCFP consultation assessment by a member of a multi-disciplinary team of mental health providers (e.g., psy-chiatrists, psychologists) who are bilingual and/orbicultural, trained in culturally competent techniques,and familiar with the cultures and languages of the cli-ents served. The Engagement Interview Protocol andDSM-IV-TR Cultural Formulation model will be utilizedto make a culturally appropriate diagnosis, assess thepatient ’ s psychiatric needs in a cultural context, conducta culturally focused intervention, engage the patient, andmake recommendations to the PCP [15,20,21]. The CFP clinician will work collaboratively with the patient ’ s PCPto communicate diagnostic and treatment recommenda-tions after the two-week follow-up visit. Given the criti-cal nature of communicating the CFP findings to thePCP, the CFP clinician will work with the PCP to deter-mine his preferences for communication. Recommenda-tions can be given to the PCP by multiple avenues: by e-mailed letter, and/or by page or phone call as needed.Clinicians will make themselves available to PCPs on anas-needed basis throughout the study period.2) Patients will receive a culturally appropriate CFPconsultation patient toolkit, available in their languageof preference (i.e., English, Spanish, Chinese, or Vietna-mese), as well as training in using the toolkit materials.The patient toolkit was added to enrich the interventionby providing patients with psychoeducation, handoutson managing depression based on cognitive behavioraltherapy techniques, and information on community resources [22]. To help in the management of their   & 1  PHQ-2 screen to be completed by patients at PCP clinics. 2  Includes structured interview, self-report measures (e.g., depressive symptoms, service utilization) and electronic   medical record review; letter withrecommendations to primary care provider sent either after baseline or two-week follow-up. 3  Includes self-report measures (e.g., depressive symptoms, service utilization) and electronic medical record review. 4 Qualitative interviews conducted after six-month assessment with study participants and members of target population. Primary Outcomes  -Evaluation of Project Implementation -Provider and Patient Satisfaction (Treatment Arm Only) -Cost Analysis Exploratory Outcomes: -Description of study population -Quantifying the effect of intervention on Depression-related outcomes   Random  Assignment by Primary Care Practice Intervention Group: CFP Consultation Initial Screen (includes PHQ-2) 1 Comparison Group: Treatment as Usual Initial Screen (includes PHQ-2) Two-Week Follow-Up Review CFP Toolkit Six-Month  Assess 3,4  Six- Month  Assess 3,4 Baseline  Assess 2  CFP Consult & Toolkit Baseline  Assess 2   Figure 1  Clinical Research Intervention Design .  Trinh  et al  .  BMC Psychiatry   2011,  11 :166 4 of 10  depression, patients will be encouraged to completethese materials and bring them to visits with their PCP.In addition, within two weeks of the initial consultation,patients will attend a follow-up visit with the CFP clini-cian to review and answer their questions about thetreatment of their depressive symptoms. The CFP clini-cian will also review patients ’  understanding of thetoolkit, including their use of the cognitive-behavioralbased handouts. To add flexibility in follow-up forpatients, these visits can be done in person or over thephone. CFP Intervention Training At the beginning of the study, CFP clinicians attend fourhour-long training sessions on the CFP consultationstudy procedures to ensure that the intervention isapplied in a standard fashion. Clinicians will audiotapeall CFP sessions, and a weekly group supervision meet-ing for CFP clinicians will be held to review cases andprovide supervision for issues related to clinical diagno-sis and intervention. Finally, the CFP consultation ser- vice will meet weekly to discuss consultation requests,follow up on the impact of consultations, and to addressother logistic issues. Inclusion/Exclusion Criteria Patients will be included based on the following criteria:adults who 1) are 18 years of age or older; 2) are mem-bers of either targeted Asian American or Latino Ameri-can minority groups; 3) screen positive for symptoms of depression; and 4) are able to consent to study partici-pation. Patients will be excluded if they have activeunstable, untreated psychiatric illness precluding partici-pation in the study (e.g., actively suicidal or homicidalor actively psychotic). Patients in the intervention armwill be excluded if they have bipolar disorder. Target PCP practices The intervention will be conducted at four MGH pri-mary care practices; each PCP practice consists of multi-ple sub-practices called pods. Recruitment strategy All patients in participating primary care clinics will beoffered screening for the symptoms of depression by thePatient Health Questionnaire-2 (PHQ-2) as part of theirroutine primary care visit [23]; data on age, gender,race, ethnicity and primary language will be obtained atthe time of screening. Asian American and LatinoAmerican patients who screen positive for clinicaldepression will be called by study staff and invited toparticipate in the CFP consultation intervention. Patientsalso may be referred by participating PCPs. For the qua-litative interviews, a subset of study participants will beinvited to participate after the six-month follow-up visit,as well as eligible members of the target population whonot participate in the study. Randomization scheme Primary care patients at MGH will be randomized by pods, which comprise multiple clusters of 5-6 PCPswithin each practice site. Using electronic medicalrecords data from 2007, practices will be matched basedon an index composed of two variables: 1) the numberof patients who are members of the target minority groups and 2) the rate of diagnosed depression. Withineach pair, one practice will be randomized to participatein the intervention and the other will be assigned to the “ usual care ”  arm. Target Health Condition All patients in the intervention and usual care (control)arms will be screened for clinical depression using theself-rated PHQ-2 at their primary care visit. Bothpatients and PCPs will be notified of positive screeningresults for all patients assessed. For the interventionarm, diagnoses of specific depressive disorders (majordepressive disorder, dysthymia, depressive disorderNOS, adjustment disorder with depressed mood) will beestablished during the baseline clinical interview usingDSM-IV-TR criteria [21]. Definition of Usual Care PCPs of those patients who screen positive on the PHQ-2 in the usual care arm will receive written feedback ontheir patients ’  PHQ-2 results, in addition to a standardlist of referrals to MGH mental health resources. At theend of the study, patients in the usual care arm will beoffered the intervention. Human Subjects Approval All study procedures have been approved by the hospitalInstitutional Review Board (IRB). Analytic Plan  Description of Measures  (See Table 1): Initial Screen On the screening form, patients will be administeredthe PHQ-2 and asked additional questions about gen-der, age, race, ethnicity, and language spoken at home.Using a cutoff score of two or above (out of a possibletotal score of six), the PHQ-2 has been validated fordiagnosing any clinical depressive disorder with a 82.1percent sensitivity, 80.4 percent specificity, and a posi-tive predictive value of 48.3 percent (assuming 18 per-cent prevalence of any depressive disorder) [23]; itconsists of the first two questions of the PHQ-9, which  Trinh  et al  .  BMC Psychiatry   2011,  11 :166 5 of 10
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