Patients Who Describe Life as Hopeless
Ms. Lee is a 48-year-old-married mother of 2 teenagers who works full-time as a store manager. Over the past 2 months, she has developed symptoms of fatigue, irritability, general aches and pains, loss of appetite, and reduced libido. She had been her mother’s primary caregiver until 4 months ago when her mother lost her battle with cancer. Her husband is supportive but feels unable to deal with her symptoms, and her children avoid her because of her temper and frequent outbursts of anger. She was a regular churchgoer who participated in social and community events but stopped attending events 1 month ago.
She presented today for an evaluation. Her physical examination, including the Mini-Mental State Examination, was normal, but she burst into tears midway through the examination and admitted that she felt that life was hopeless. A suicide screen was negative. A screening complete blood count with differential, basic metabolic panel, and thyroid function tests are normal.
Questions to Consider
- Are there differences in the risk factors for depression among cultural or ethnic groups? Does presentation differ, and how might this affect recognition?
- If Ms. Lee were black, Latino, or Asian, how might her attitude toward depression treatment differ from those of a white patient?
- What communication and treatment strategies are likely to reduce disparities in mental health care for depression?
Recognizing the Many Faces of Depression
Depression was the fourth leading cause of disability worldwide in 2000 and is projected to be the second leading cause by the year 2020. The lifetime prevalence for adults in the United States is estimated to be 16%. Although the prevalence of depression is largely similar among ethnic groups, differences in recognition and diagnosis of depression between white and minority patients have been noted. A 2001 Surgeon General’s report highlighted this finding.
Over the past decade, recognition and treatment rates for depression have increased dramatically in both primary and psychiatric settings, with a shift seen in treatment approach from psychotherapy to antidepressants. Much of the increase in prescription use was the result of care by psychiatrists. However, ethnic and racial disparities in treatment continue to be significant and may even be worsening.[6,7]
Ethnic minorities are less likely to be seen by psychiatrists and more likely to be seen in primary care, and lower rates of recognition of depression in primary care may result in disparities in treatment. A 10-year analysis (1995-2005) of depression in ambulatory care found that, although disparities were largely eliminated in psychiatric care, they remained in primary care for blacks and Hispanics in particular. Disparities ran the gamut from diagnosis, to referral for counseling, to prescription for antidepressants. These disparities can be partially explained by cultural and linguistic barriers.
Although low socioeconomic status has been noted as a risk factor for major depression, the effect of household income and employment on major depression differs by race and ethnicity. Gavin and colleagues reported that attainment of higher education was associated with lower risk for depression among white men but not other groups. Unemployment was a significant risk factor for major depression among whites and US- and foreign-born Latinos. Compared with whites, the rate of depression was lower than expected among blacks, Latinos, and Asians with lower education, income, and higher unemployment. The study authors concluded that different ethnic groups experience life events and socioeconomic and educational status differently, and that this affects depression risk.
Among some Asian Americans, social stigma is a strong disincentive to seek treatment for depression, and symptoms may present as physical discomfort rather than sadness or the typical presentations of depression. Among community-dwelling adult Korean Americans, for example, higher education among both immigrants and US-born persons has been associated with greater likelihood of accepting treatment for depression. Female minorities are also more likely to accept the diagnosis and to seek treatment than their male counterparts. Thus, multiple factors, including race, ethnicity, gender, culture, and ancestry, all affect what a patient may report, and clinician factors may influence interpretation of symptoms and the type of treatment that is subsequently offered and accepted.
Treating Depression: Do Disparities Persist?
Adding to the burden of differential risk and recognition of depression among ethnic and racial groups, distinct differences in attitudes toward treatment methods underscore differences in outcomes. Minorities are less likely to use specialty mental health services, experience longer delays to receipt of psychotherapy, and have lower rates of adherence to medications compared with whites. For example, among a multiethnic group of over 78,000 patients with depressive symptoms, a cross-sectional Internet survey found that, compared with whites, blacks, Latinos, and Asians/Pacific Islanders were 1.8-2.6 times more likely to prefer counseling to medications. These patients were also more likely to believe that antidepressants were addictive and less effective than other methods. Prayer was believed to be more effective among blacks, a finding replicated in other studies. A cross-sectional survey of black and white adults attending primary care clinics found that blacks were 3 times more likely than whites to rate spirituality as extremely important for depression care. A qualitative study of older black persons reported a high prevalence of a faith-based explanatory model for depression in which faith and religious activities were believed to be empowering when combined with medical treatment to improve care.
The importance of clinician recognition of stereotyping and bias in the therapeutic setting was illustrated by another study that found that stigma and racism contribute to lower rates of care-seeking for mental health among blacks. In a telephone survey of 829 adults who reported at least 1 week of depressive symptoms in primary care and who met criteria for major depressive disorder within 1 year, blacks and Latinos were found to be less likely (odds ratio [OR], 0.30 and 0.44, respectively) than whites to consider antidepressants acceptable. This same study found that blacks were also less likely (OR, 0.63) to find counseling acceptable in contrast to Latinos, who were 3.26 times more likely than whites to find counseling acceptable. A review of mental illness among Latinos also noted the low medication adherence rate in this group but a corresponding high acceptability of counseling and psychosocial and psychotherapeutic interventions for depression. Among Chinese Americans, the stigma associated with depression has been found to account for lower rates of recognition and treatment regardless of birthplace or ancestry. Cultural factors, rather than language barriers or immigration status, may play more important roles in attitude differences.
The Importance of Cultural Competence
These findings underscore the importance of considering the patient’s social and cultural context when negotiating treatment decisions for depression. Culturally appropriate interventions that improve outcomes of care for depression have been described. For example, cultural adaptation of a treatment that involved improved cultural competency of providers to address client-centered goals led to higher participant adherence, satisfaction, and retention among low-income mothers with depression. Depression prevention strategies have also been successfully adapted for low-income mothers.[20,21]
Among black patients, involvement of a religious or spiritual leader is likely to improve retention and medical treatment rates for depression.
A program for Chinese Americans, which trained primary care physicians on current depression treatment guidelines, provided cultural competency training to nurses and physicians, and used a nurse as the bridge to access on-site psychiatric services, improved recognition of depression by 60% over a 1–year period. This same program increased the engagement of patients with psychiatric services from 53% to 88%.
The Kleinman Questions
In Chinese Americans, a culturally sensitive, primary-care based, collaborative treatment that involved bilingual providers to elicit patients’ explanatory model of illness led to a 7-fold increase in treatment rates for depression. This study used a group of exploratory questions, now named the Kleinman questions for the lead author. The Kleinman questions elicit the patient’s perspective of illness and are widely used.
These questions are simple to deploy and may be selectively used in clinical interviewing to address issues of diagnosis, treatment options, and expectations as they emerge:
- What do you think has caused your problem?
- Why do you think it started when it did?
- What do you think your sickness does to you?
- How severe is your illness? Is it a short or long course?
- What kind of treatment do you think you should receive?
- What are the most important results you hope to achieve from this treatment?
- What are the chief problems your sickness has caused for you?
- What do you fear most about your sickness?
Back to the Case
If Ms. Lee were Asian American, for example, she might be reluctant to accept a diagnosis of or to receive counseling for depression because of perceived stigma, and she might internalize her symptoms and instead seek family support. However, a care manager in a culturally congruent setting might be able to advance her care. If she were Hispanic, she might be more likely to accept counseling and less likely to embrace pharmacotherapy, so counseling could be an appropriate first option. If she were black, she might prefer to seek religious or spiritual guidance before medical treatment. An individualized approach that elicits patient beliefs about the illness, encourages patient engagement, and uses culturally appropriate interventions is likely to result in better recognition, treatment adherence, and quality outcomes.
Ethnic and racial disparities in mental health care have profound treatment implications for individuals and broader society. Although race is a social and not a biological construct, it may nevertheless lead to assumptions and stereotypes about patients by providers that result in disparate care. Providers need to be aware of different presentations of depression among cultures, genders, and other groups as well as attitudes toward treatment methods that will affect adherence.
Race concordance between provider and patient has been shown to promote better outcomes and to reduce disparities; however, it is unlikely that the disparity between the number of white and minority healthcare professionals will change anytime soon. Every provider should therefore be prepared to use communication tools, such as those detailed in the Table, that permit patient-centered interviewing to address the patient’s explanatory model of health and illness in negotiations for best treatment outcomes.
Table. Cultural Competency Tools and Resources
|Multicultural resources for health information|
|U. S. Department of Health and Human Services Office of Minority Health: Think Cultural Health|
|A Physician’s Practical Guide to Culturally Competent Care|
|Health Resources and Service Administration: Culture, Language and Health Literacy|
|Walking In Their Shoes: Enhancing Authentic Practitioner-Patient Communication|
- World Health Organization. Depression. http://www.who.int/mental_health/management/depression/definition/en/ Accessed July 26, 2012.
- Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289:3095-3105. Abstract
- Miranda J, McGuire TG, Williams DR, Wang P. Mental health in the context of health disparities. Am J Psychiatry. 2008;165:1102-1108. Abstract
- United States Department of Health and Human Services. Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md: Center of Mental Health Services, Substance Abuse and Mental Health Services Administration; 2001.
- Stockdale SE, Lagomasino IT, Siddique J, et al. Racial and ethnic disparities in detection and treatment of depression and anxiety among psychiatric and primary health care visits, 1995-2005. Med Care. 2008;46: 668-677. Abstract
- Blanco C, Patel SR, Liu et al. National trends in ethnic disparities in mental health care. Med Care. 2007;45:1012-1019. Abstract
- McGuire TG, Miranda J. New evidence regarding racial and ethnic disparities in mental health: policy implications. Health Aff (Millwood). 2008;27:393-403. Abstract
- Gavin AR, Walton E, Chae DH, Alegria M, Jackson JS, Takeuchi D. The associations between socio-economic status and major depressive disorder among blacks, Latinos, Asians and non-Hispanic whites: findings from the Collaborative Psychiatric Epidemiology Studies. Psychol Med. 2010;40:51-61. Abstract
- Yeung A, Chan R, Mischoulon D, et al. Prevalence of major depressive disorder among Chinese-Americans in primary care. Gen Hosp Psychiatry. 2004;26:24-30. Abstract
- Yi SH, Tidwell R. Adult Korean Americans: their attitudes toward seeking professional counseling services. Community Ment Health J. 2005;41:571-580. Abstract
- Wang PS, Berglund P, Olfson M, et al. Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:603-613. Abstract
- Givens JL, Houston TK, Van Voorhees BW, et al. Ethnicity and preferences for depression treatment. Gen Hosp Psychiatry. 2007;29:182-19.1
- Cooper LA, Brown C, Vu HT, Ford DE, Powe NR. How important isintrinsic spirituality in depression care? A comparison of white and African-American primary care patients. J Gen Intern Med. 2001;16:634-638.
- Wittink M, Joo J, Lewis L. Losing faith and using faith: older African Americans discuss spirituality, religious activities, and depression. J Gen Intern Med. 2009;24:402-407. Abstract
- Buser JK. Treatment-seeking disparity between African Americans and whites: attitudes toward treatment, coping resources, and racism. Journal of Multicultural Counseling and Development. 2009;37:94-104.
- Cooper L, Gonzales J, Gallo J, et al. The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients. Med Care. 2003;41:479-489. Abstract
- Marin Ho, Escobar J, Vega W. Mental illness in hispanics: a review of the literature focus. 2006;4:23-37. http://focus.psychiatryonline.org/article.aspx?articleid=50420 Accessed July 31, 2012.
- Chen AW, Kazanjian A, Wong H. Why do Chinese Canadians not consult mental health services: health status, language or culture? Transcult Psychiatry. 2009;46:623-641.
- Feinberg E, Stein R, Diaz-Linhart Y, et al. Adaptation of problem-solving treatment for prevention of depression among low-income, culturally diverse mothers. Fam Community Health. 2012; 35:57-67. Abstract
- D’Angelo EJ, Llerena-Ouinn R, Shapiro R, et al. Adaptation of the preventive intervention program for depression for use with predominantly low-income Latino families. Fam Process. 2009;48:269-291 Abstract
- Silverstein M, Feinberg E, Cabral H, et al. Problem-solving education to prevent depression among low-income mothers of preterm infants: a randomized controlled pilot trial. Arch Womens Ment Health. 2011;14:317-324. Abstract
- Yeung A, Yu SC, Fung F, et al. Recognizing and engaging depressed Chinese Americans in treatment in a primary care setting. Int J Geriatr Psychiatry. 2006;21:819-823. Abstract
- Kleinman A, Eisenberg L, Good B. Culture, illness and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88:251-258. Abstract
- Schraufnagel TJ, Wagner AW, Miranda J, Roy-Byrne PP. Treating minority patients with depression and anxiety: what does the evidence tell us? Gen Hosp Psychiatry. 2006; 28:27-36.
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