Primary Care Takes Course on Cultural Issues in Depression

A collaborative educational project between APA and the National Alliance on Mental Illness (NAMI) is helping to facilitate diagnosis and treatment of depression in minority and underserved patients in the setting where they are most likely to appear—primary care.

The course is being offered through APA's Office of Minority and National Affairs and NAMI's Muticultural Action Center. It's being presented around the country and has already drawn physicians and allied health professionals to New Orleans, St. Louis, and Los Angeles to learn about cultural factors that impact minorities with depression.

At the first course, offered at the Institute on Psychiatric Services in New Orleans last October, attendees learned about issues such as how the cultural backgrounds of patients and physicians can affect diagnosis and treatment; how stigma surrounding mental illness may affect the care that primary care physicians provide; and how race and ethnicity can affect metabolism of certain medications.

“Racial and ethnic disparities in depression care include a smaller likelihood of accurate diagnosis and less guideline-consistent care for those who are diagnosed,” stated presenter Ayanna Buckner, M.D., M.P.H., a primary care physician in Atlanta and an assistant professor in the Department of Community Health and Preventive Medicine at Morehouse School of Medicine.

Likewise, minorities are much more likely than nonminorities to seek treatment for mental health problems in the primary care setting, according to Opal Walker, R.N., M.B.A., who spoke from the perspective of a former psychiatric nurse and the family member of someone with major depressive disorder. She is also a medical surveyor for the state of Louisiana.

Walker cited data from Mental Health: Culture, Race, Ethnicity: Supplement to Mental Health: Report of the Surgeon General, published in 2001, and other studies to illustrate the need for better depression diagnosis in primary care settings.

For instance, only 4 percent of Asian Americans indicated that they would seek help from a mental health specialist vs. 26 percent of whites, according to the report.

Other data cited in the report showed, for example, that 1 in 11 Latinos with mental disorders contacted mental health specialists for treatment whereas about 1 in 5 contacted their primary care provider.

Walker and Buckner stressed the importance of asking patients about spiritual beliefs and traditions. “Be aware of the role of the patient's spiritual beliefs and practices because they may influence whether the person stays in treatment,” Walker said.

According to Walker, people of color are more likely to respond favorably solely to spiritual support in lieu of professional treatment for mental health problems.

At the same time, patients' spirituality may not only coexist with“ traditional” mental health treatment, but may be used as a tool in conjunction with medications and/or psychotherapy to help the person recover from mental illness, they noted.

Buckner pointed out that sometimes primary care physicians are affected by the entrenched stigma surrounding mental illness and may thus not ask questions that will help them learn more about patients' mental health status.

Time constraints may also hinder the screening process, she noted. In focus groups of primary care physicians organized by APA and NAMI earlier this year, one commented that physicians may be reluctant to ask about psychiatric medications the patient is taking, for instance, because “they don't want to bring up a situation that might embarrass the patient and lengthen the visit when they may already be behind schedule,” according to Buckner.

When asking her minority patients about mental health issues, Buckner said that she explains that, much in the same way that she screens and treats them for hypertension and diabetes, it is important that she do so for depression, which is also a serious medical problem.

She recommended use of the Patient Health Questionnaire-9 to screen patients for depression.

Buckner also pointed out that people from minority groups may express depressive symptoms in ways that can be misinterpreted by clinicians who are not aware of certain cultural norms.

For instance, African Americans with depression may complain of irritability, hostility, or vague somatic symptoms, and it is not uncommon for Asian Americans to complain of weakness or dizziness when they are depressed. Latinos may complain of having problems with their “nerves” or having “heartache,” she explained.

Likewise, it is essential for primary care physicians to understand the way medications are metabolized among certain minority groups. “African Americans and Asian Americans often experience a decreased metabolic rate of certain psychotropic medications, including antidepressants,” Buckner said.

This difference is related to how certain cytochrome P450 isoenzymes are expressed.

So patients don't become non-compliant with medications due to the side effects that may result from being administered the wrong dose of medication, Buckner urged clinicians to “start low and go slow,” meaning it is best to err on the side of caution by starting with a low dosage and titrating it upwards gradually.

“We want to keep these patients engaged as we navigate through what can be a tricky process” of adjusting medication levels to ensure recovery, she noted.

Debra LaVergne, a consumer affairs specialist with the Louisiana Department of Health and Hospitals' Office of Mental Health, one of the presenters, offered the consumer's point of view as someone who struggled with bipolar disorder.

Almost a decade ago, LaVergne's primary care physician noticed that she needed treatment for a condition that was robbing her of the things she most prized: family, work, and her sense of self-worth. The“ lifesaving” visit to her primary care doctor was the first step on her path to recovery, she said.

Before being diagnosed, LaVergne said she felt “lost, lonely, and hopeless.” She was sleeping 16 to 18 hours a day and rarely left her bedroom. She eventually lost her job and almost lost her marriage.

Receiving a diagnosis was a relief, she noted, because she realized that there was a biological cause for her experiences. While in treatment, Lavergne said, her physician included her in treatment decisions and encouraged her to become an expert on her own illness. “This was quite an empowering experience,” she said.

The APA-NAMI collaboration, “Eliminating Disparities in Depression Care: Depression Treatment in Primary Care,” is supported by a grant from Praxis Partnership, a consortium of the University of Alabama at Birmingham, Vanderbilt University, and Indicia Medical Education, L.L.C. Praxis is funded by an unrestricted educational grant from Wyeth Pharmaceuticals.

More information about “Eliminating Disparities in Depression Care: Depression Treatment in Primary Care” is available by contacting Alison Bondurant at APA's Office of Minority and National Affairs by e-mail at [email protected].▪