Culturally Focused Consultation Enhances Integrated Care

A culturally informed short-term consultation with Latinos who are experiencing depressive symptoms may augment treatment as part of an integrated approach to depression in the primary care setting, according to a study published in the October Psychiatric Services.

“We found that a brief psychiatric consultation with a cultural focus can positively impact depressive symptoms among these Latino primary care patients,” principal investigator Nhi-Ha Trinh, M.D., M.P.H., of Massachusetts General Hospital and Harvard Medical School, told Psychiatric News.

Study participants included 118 Latino adults attending four primary care clinics affiliated with Massachusetts General Hospital who screened positive for likely depression. Clusters of participating primary care providers at each of the four clinics were randomly selected to administer either a two-session culturally focused psychiatric consultation (CFP) or enhanced usual care. Randomization was based on the clinic rather than the patient, as a way to prevent providers from being exposed to the intervention and then unintentionally providing it to usual-care study subjects.

For CFP intervention participants, study clinicians (psychologists or psychiatrists) provided a mental health assessment, psychoeducation, cognitive-behavioral tools, and tailored treatment recommendations; primary care providers were given a consultation summary. The DSM-IV-TR cultural formulation model and Engagement Interview Protocol were applied to engage the patient, inform culturally appropriate diagnosis, and provide tailored treatment recommendations. Study clinicians also had access to participants’ electronic health records.

Participants were also offered a second visit within two weeks, during which the clinician addressed participants’ questions and adherence to recommendations.

In enhanced usual care, primary care providers were notified via e-mail of positive depressive symptom screens, and participants received usual care for depression through their primary care practice.

Although depressive symptoms remained in the moderate range for both groups from baseline to six months, symptom reduction was greater among CFP intervention participants than those in usual care. Statistical analysis indicated that participation in the CFP intervention predicted lower depressive symptoms at follow-up, independent of baseline depressive symptoms, clinic site, age, gender, and employment status.

Trinh said the majority of participants were foreign-born, monolingual Spanish speakers, with half receiving some type of treatment for depression prior to participating in the study.

He said a number of cultural barriers may call for a culturally sensitive approach to care of depression in Latino patients.

“On the provider level, it may be challenging for a primary care provider to assess depression in a patient with whom they differ in ethnicity or culture,” he said. “This may be due to variation in symptom presentation or the terms used by Latinos to describe their experience with depression. Primary care providers may also have varying levels of experience in treating depression, and this may be complicated when working with patients with complex comorbid psychosocial problems.”

At the patient level, Latinos may lack knowledge about depression symptoms and treatment options and may be especially affected by a cultural stigma surrounding mental illness. Patient treatment preferences may differ from standard treatment recommendations, and Latinos may generally lack experience with the U.S. mental health care system, Trinh said.

He noted that the findings from the study support the use of a short-term consultation focusing on cultural factors that may influence Latino patients’ perception of depression and treatment and an integrated approach to care of depression in primary care. “Such findings add to a growing literature on the benefits of collaborative care among primary care and mental health specialists,” he said. ■