Depression Treatment in Primary
Care Settings:
An APA-NAMI Collaborative CME
Approach to Eliminate Disparities
for Racial/Ethnic Communities
October 19, 2010
Diversity Rx 2010 National Conference
On Quality Health Care for Diverse Populations
Baltimore, Maryland
Annelle B. Primm, M.D., MPH
Director, Minority and National Affairs
American Psychiatric Association
[email protected]
In Living Color
3 hour CME curriculum, NAMI-APA effort
Focuses on treating Depression in Diverse
Populations for primary care
Taught by teams consisting of a physician,
person with history of depression and a family
mental health advocate
Combines the science and the lived
experience of depression among diverse
Curriculum Goals
Equip primary care practitioners with the
appropriate knowledge and tools to identify
and provide treatment of depression in
diverse populations
Create awareness of cultural influences and
how depression manifests within a cultural
Model successful communication and
partnership between providers and patients
of different cultures
Course Topics – A Sampling
Recognizing depression in diverse racial
and ethnic groups
Overcoming challenges in diagnosis and
treatment in these populations
Recognizing cultural influences on mental
Successful communication
Course Topics – A Sampling
Basic Principles of Quality Care
Person-centered care
 Culturally competent care
 Recovery-oriented care
Treatment and referral
APA – American Psychiatric Association
NAMI – National Alliance on Mental Illness
Curriculum authors:
 Annelle B. Primm, M.D., MPH, APA Office
of Minority and National Affairs
 Majose Carrasco, MPA, Director, NAMI
Multicultural Action Center
Supported by a grant from Praxis Partnership,
a consortium of UAB Birmingham, Vanderbilt
University, Indicia Medical Education, LLC
which received its funds from an unrestricted
grant from Wyeth
Inspiration and Collaboration
Depression is a prevalent illness found in
primary care, costly to treat but even more
costly if untreated
Depression is commonly missed or
Routine screening is recommended as locally
accepted best practice in many areas and
required by some health care systems and
Disparities in quality depression care exist
among patients of diverse populations in
whom depression is often undetected or
Unique Characteristics
Innovative presentation format
Presented by a team of 3 trained facilitators (1
physician and 2 consumers/family members
Models effective clinician/patient interaction
Promotion of consumer-centered treatment
President’s New Freedom Commission
Report in 2003 recommended that people
with mental illness actively participate with
health care professionals in designing,
developing systems of care in which they are
Pilot Phase and Evaluation
Facilitator training
Program piloted in Los Angeles, St. Louis and
New Orleans
45 primary care practitioners participated
Overwhelming positive response to the
patient perspective
86% of participants rated the content of the
course as excellent or good
97% of participants found the curriculum
helpful in addressing barriers to and
approaches for depression care
Statistically significant perceived
improvement in 5 out of 7 items from pre to
post test
The importance of the role of the clinician’s race,
ethnicity and worldview in evaluation and treating
patients of different backgrounds
Clinician’s level of confidence in ability to
communicate effectively with patients from diverse
groups regarding the diagnosis and treatment of
Clinician’s confidence in determining when it is
appropriate to refer a person with depression to a
psychiatrist for treatment
Part 1: Understanding Depression, Culture
and Consumer-Centered Care
Part 2: Recognition and Diagnosis
Part 3: Treatment, Referral and Adherence to
Learning Objectives
Interpret how depression manifests itself
in racially and ethnically diverse
Identify depression screening, diagnosis
and treatment options
Understand how the patient’s and
physician’s cultures can affect diagnosis
and treatment
Develop strategies for effective
physician-patient communication
Depression: The Burden of Suffering
Lifetime risk: 13% - 16%. (Hasin et al, 2005; Kessler et al,
Functional impairment caused by depression is similar to
that of many chronic diseases
More than 50% of patients see only primary care
providers (Sturm et al, 1996)
Prevalence in primary care: 15-22% overall
major depression 5-9%
dysthymia 2-4%
minor depression 8 -10% (National Library of
Medicine, 2005)
Under-recognition & Treatment
Only a fraction properly diagnosed and treated
About 50% of depression cases are missed in
primary care settings. (Goldman et al,1999)
Diverse populations more frequently
undiagnosed and undertreated
African Americans and Latinos/Hispanics are less
likely to receive care consistent with practice
guidelines (Wang et al 2000)
Disparities in Depression Treatment
Of people with depression % not
accessing any mental health treatment
in the past year:
African Americans
Alegria et al , 2008
Culture Counts: Influences on
Mental Illness & Mental Health
Communication (verbal and non-verbal)
Manifestation of symptoms
Family and community support
Health-seeking behaviors
Support systems and protective factors
How people perceive & cope with mental illness
How clinicians interact with people with mental
Stigma and shame associated with mental illness
Spirituality (predestination, views of illness, etc)
(Surgeon General, 2001)
Spirituality and Alternative Sources of Care
Spirituality has an important role in many racial/ethnic communities.
Can promote mental health education and prevention
Key source of support (Surgeon General, 2001)
However, people of color may rely solely on spiritual support in lieu
of professional treatment.
Propensity to use alternative care for religious or cultural reasons:
12% of African Americans
27% of Asian Americans
22% of Hispanics
4% of Non-Hispanic Whites
(Collins et al, 2002)
Lifetime help-seeking from traditional or spiritual healer for psychiatric
disorders in American Indians:
 37% and 20% males (Southwestern and Northern Plain tribes)
 41% and 19% females (Southwestern and Northern Plain tribes)
(Beals et al, 2005)
Basic Principles of
Quality Care
Recovery-Oriented Care
It is important to convey a sense of hope and the
fact that depression is treatable.
“The American Psychiatric Association endorses
and strongly affirms the application of the
concept of recovery …. The concept of recovery
emphasizes a person’s capacity to have hope
and lead a meaningful life, and suggests that
treatment can be guided by attention to life goals
and ambitions. It focuses on wellness and
resilience and encourages patients to participate
actively in their care ….” (APA, 2005)
Culturally Competent Care
“Cultural competence is a set of values,
behaviors, attitudes, and practices within a
system that enables people to work
effectively across cultures.” (Office of Minority Health)
Cultural competence is the ability to work
effectively and sensitively within various
cultural contexts.
Characteristics of
Culturally Competent Care
Cultural self-awareness (introspection)
Awareness of the cultural context of the
Understanding the dynamics of the
Development of cultural knowledge
Ability to adapt and practice skills to fit the
cultural context(s) of others
Skills Development:
The LEARN Model
Listen with empathy and understanding to the person's
perception of the situation.
Elicit culturally relevant information and Explain your
perception of the situation.
Acknowledge the similarities and differences between
your perceptions and theirs.
Recommend options/alternatives and Respect the
person and her choices.
Negotiate agreement.
(Berlin & Fowkes, 1983)
Person-Centered Care
Person-centered care: healthcare partnership among practitioners,
patients, and their families to ensure that decisions respond to
and respect patients' wants, needs, and preferences and solicit
patients' input on the education and support they need to make
decisions and participate in their own care. (Adapted from Agency for
Healthcare Research and Quality, 2002)
Six dimensions of person-centered care:
Respect for patient’s values, preferences, and expressed
Coordination and integration of care
Information, communication, and education
Physical comfort
Emotional support
Involvement of family and friends
(Gerteis et al, 1993)
Physician’s Communication
“Focusing attention on patient-centered communication is not
merely an ethical imperative in health care; we also believe it will
lead to better health outcomes. Communication barriers are
especially prevalent among vulnerable minority populations, and
efforts to improve patient-centered communication may help
alleviate racial and ethnic disparities in health care.”
(American Medical Association, 2006)
 Data-gathering
 Relationship-building
 Partnering
 Patient education and counseling
 Facilitation and patient activation
 Avoidance of verbal dominance
(Adapted from Cooper et al, 2007)
Depression in Primary Care:
Recognition and Diagnosis
 Screening—the PHQ-9
 Detection of suicidal ideation
 Dual diagnosis
Diagnostic Criteria:
Major Depressive Disorder
At least five of the following symptoms most of the day,
nearly every day for at least two weeks:
 Depressed mood
 Diminished interest or pleasure in most activities
 Insomnia or hyper-somnia
 Significant weight loss or gain
 Feelings of guilt or worthlessness
 Fatigue (loss of energy)
 Impaired concentration
 Psychomotor retardation or agitation
 Recurrent thoughts of death or suicide
(American Psychiatric Association, 2000)
Presenting Depression
Complaints Across Cultures
(Kales et al, 2005; Tseng and Streltzer, 1997; Mezzich et al, 1996
Depression and Suicide
Major depression accounts for about 1/3 of all suicides, and all mood
disorders together account for 2/3 of suicides. (SAMHSA, 2007)
The lifetime risk of suicide among people with untreated severe depression
is nearly 20%. (Gotlib & Hammen, 2002)
One study reported that “suicide by cop” accounted for 11% of officerinvolved shootings. (Hutson, 1998)
Suicide rates are highest among whites and second highest among
American Indian and Native Alaskan men. (CDC, 2007)
Among Asian Americans, there is a greater suicide rate among elderly
women and those ages 15-24 years. (Surgeon General, 2001)
Caribbean men have particularly high rates of suicide attempts. (Joe et al,
Substance Abuse and Depression
Depression and substance abuse commonly co-occur.
Almost 1/3 of primary care patients diagnosed with
depression reported either hazardous drinking, use of
illicit drugs, or misuse of prescription drugs. (Roeloffs
et al, 2002)
Untreated depression can increase the risk of
substance abuse (self-medication) and vice versa.
There is greater exposure and accessibility to
drugs/alcohol in communities of color.
Substance abuse is highest among American Indians
and Alaska Natives (21.0%) and lowest among Asians
(4.5%). (SAMHSA, 2005)
Depression and Co-morbidity
Depression should not be explained away by the
existence of other medical conditions.
Medical conditions commonly associated with
- Stroke
- Diabetes
- Cancer
- Fibromyalgia
- Dementia
- Coronary artery disease
- Chronic fatigue syndrome
Other Considerations
 Major
depression versus other mood
 Concurrent
 Other
stressors: poverty, loss of
employment, traumatic loss, etc
Depression in Primary Care:
Treatment and Referral
Depression Care Process
The clinician and the person with depression select a
management approach for treatment:
Watchful waiting
Combination of antidepressants and counseling
The clinician and support staff monitor adherence
to the plan and improvement in symptoms/
function and modify treatment as appropriate.
Self-monitoring: The person with depression tracks
improvements, symptoms, and set-backs, and
reports information to the doctor.
(Adapted from MacArthur Initiative on Depression and Primary Care)
Shared Decision Making
Doctor and consumer work together to make health care
decisions that are informed by:
The best available evidence about treatment, screening, and
illness-management options
Potential benefits and harms, taking into account the consumer’s
Doctor involves consumer in treatment decisions by:
Offering choices
Discussing pros and cons
Asking for preferences and opinions
Negotiating and reaching a mutually agreeable treatment plan
Treatment Preferences
If diagnosis is confirmed, educate on the following:
Treatment options and processes
Peer supports
During conversation about treatment options, consider the
Cultural and social context—e.g., language
Religious and spiritual beliefs
Views of illness
Level of understanding
Family dynamics
Factors Determining
Pharmacological Response
side effects
(Henderson, 2007)
Ethnic and racial variation in response
to psychotropic medication due to
specific polymorphic variability which
affects drug metabolism
Factors such as age, gender, diet and
smoking also play a role in determining
differential response
Cytochrome P450 (CYP450) drug-metabolizing
 >20 human CYP450 enzymes identified1
 Metabolize antidepressants, antipsychotics, and
 Most relevant to psychiatric treatment include1,2:
1.Smith, MW. Ethnopsychopharmacology. In: Lim RF (ed). Clinical
Manual of Cultural Psychiatry. Arlington, VA: AP Publishing, Inc.;
2.Bondy B. Dialogues Clin Neurosci. 2005;7:223.
The Ethnopsychopharmacological
 Cultural formulation for diagnosis
Choice of medication
 Use medical history, concurrent medications, diet, food
supplements, and herbals combined with knowledge of
enzyme activity in certain ethnic groups
 Start at lower doses
Monitor patient
 Proceed slowly; involve family
 If side effects are intolerable, lower dosage or choose drug
metabolized through different route
 If no response, check adherence, raise dose, and monitor
levels; add inhibitors; switch drug
(Henderson, 2007)
Other Issues in Treatment
Managing side effects
Drug interactions
FDA Advisory Black Box Warning
Maintenance treatment
Psychotherapy and Counseling in Primary Care
Specialist Decision Support and Referral
Adherence to Treatment
Homelessness, substance use/abuse, support systems,
affordability, cultural norms, and side effects play a role
in adherence
Pharmacotherapy discontinuation occurs more
frequently among African Americans and Latinos than in
other groups (Brown et al, 1999, and Olfson et al, 2006)
Adherence is negatively affected by lack of physicianpatient communication and lack of cultural competence
in service delivery
Peer Supports
Peer support fosters and supports recovery because,
among other things, it can help combat the loneliness and
the sense of not belonging that people with depression
may experience.
NAMI affiliates offer free programs designed to assist
individuals and families affected by severe depression
and other mental illnesses, including:
NAMI Connection
Other organizations that offer peer services for people with
depression and other mental illnesses are:
Depression and Bipolar Support Alliance
Depression is Real Campaign
Mental Health America
The MacArthur Initiative of Depression and Primary Care
Take Away Messages
Disparities in depression care for communities of color
exist. Primary care professionals are in a key position to
help eliminate these disparities
Cultural factors are important when diagnosing and
treating depression
Person-centered, culturally competent, recovery-oriented
services are key ingredients of quality care
PHQ-9 is a quick and easy tool for detecting and
monitoring depression.
Good communication and shared decision making are
important components of the treatment process

State of Mental Health of African American and African