‘Cultural adaptations can help but may be secondary to standard collaborative care model’
Racial/ethnic minorities experience a greater burden of mental health problems than white adults in the US.
While the prevalence of mental health disorders is similar among white and non-white adults in the US, disparities in access and utilization of mental health services persist.
The reasons for reduced service use are many, including lack of insurance, language and communication barriers, and perceived stigma.
Against that background, Jennifer Hu, MD, psychiatry resident at the Cambridge Health Alliance, and colleagues, set out to summarize what is known about the impact of collaborative care on depression for racial/ethnic minorities.
Collaborative care treatment should be explored, they conclude in their report, published in the July/August edition of Psychosomatics. However, questions remain over:
The review
Most studies in the researchers’ review included Hispanic and/or black adults as part, or all, of their samples. Asian adults (primarily East Asians) and Native American adults were also included. Two studies included individuals with comorbid medical conditions.
Most studies reviewed included women, reflecting trends observed in mental health practices that women are more likely to seek and receive mental health care for depression than men.
However, results from a study including veterans showed that minority veterans had higher rates of response to collaborative care than white veterans, indicating this model may be an intervention to address untreated depression among minority men.
Full implementation of the Patient Protection and Affordable Care Act has decreased some disparities, by increasing access to behavioral health care in primary care, say the researchers. But disparities still exist, and despite the many integrated care models, few demonstrate effectiveness in addressing these disparities in clinical settings.
The findings
“There is a robust evidence base that collaborative care can improve depression outcomes for individuals, although population samples from these studies are often predominantly white adults,” say the researchers. “Results from this review show there is potential that collaborative care can effectively improve depression for racial/ethnic minority adults and that results can be sustained over time.”
Several of the studies reviewed describe difficulties recruiting minority patients for such studies. “Minority adults’ views of what depression is, and what causes it (e.g., stress and social factors), may make them less inclined to participate in studies with a focus on medication treatment (versus therapy).
“Involving family members may also be important for certain minority groups such as Hispanic Americans, for whom family cohesion and interdependence have been identified as key values.”
The researchers also noted to what extent, if any, each study incorporated cultural adaptations. These were mostly targeted toward improving patient-centered communication, which has been shown to improve patient adherence, satisfaction, and mental health outcomes. In addition, interventions that focus on cultural issues aim to increase patient knowledge, decrease barriers to access, and improve provider cultural sensitivity—all linked to improved health outcomes.
“However, there is no standard definition of culturally sensitive care; thus, results should be interpreted cautiously,” say the researchers. “Some of these cultural adaptations were as minimal as providing bilingual educational materials, while others were as intensive as using culturally adapted interview protocols and providing additional training for staff.”
One study they reviewed compares standard collaborative care with a patient-centered, culturally-sensitive, collaborative care model tailored to black patients. It highlights not only the potential for culturally sensitive care to focus on language capacity but also to incorporate culturally targeted messages that address patient beliefs and attitudes about treatment.
“Importantly, however, this same study revealed that black adults benefited from collaborative care regardless of whether there was a cultural component, suggesting the cultural component may be secondary to standard implementation of collaborative care.”
Brought together, say the researchers, the data suggests collaborative care programs targeting racial/ethnic minority patients should focus on implementing the four core components as described by the Advancing Integrated Mental Health Solutions Center and that culturally sensitive adaptations are likely secondary to this. “In other words, a high-fidelity, well-implemented collaborative care program designed with understanding of, and input from, the local context will more effectively improve depression in minority populations than a program that only boasts culturally sensitive care.”
That said, three studies in the researchers’ review incorporating telehealth all show improvement in depression for racial/ethnic minority patients: “Telemedicine has the potential to connect patients to care providers who speak the same language, or whose facilities have more robust interpreting services. It may also allow patients to speak with care providers who are trained to evaluate psychiatric diseases in specific cultural contexts.”
Socioeconomic differences among racial/ethnic minority groups (especially for white versus non-white groups) may also play a role in depression outcomes. However, most studies in the review did not comment specifically on income level, and it was difficult to draw conclusions about how patients from different socioeconomic classes may respond to collaborative care.
“A number of studies had samples that were recruited exclusively from clinics serving low-income patients (e.g., public sector clinics), and collaborative care seems to have been an effective intervention for these groups,” say the researchers. “Of note, all these studies included cultural components, ranging from bilingual screening tools to bilingual staff and culturally adapted therapy. These findings are consistent with previous ones that demonstrate collaborative care can have a disproportionate benefit to underserved communities and promote better engagement with care.”
“Black adults benefited from collaborative care regardless of whether there was a cultural component, suggesting the cultural component may be secondary to standard implementation of collaborative care.”
The researchers conclude: “Results from this review show there is potential that collaborative care in primary care settings, with or without cultural/linguistic tailoring, is effective in improving depression for racial/ethnic minority patients, including those from low socioeconomic backgrounds. Positive outcomes can occur in as little as one month and persist for up to two years.”
Nevertheless… “Questions remain as to what elements of cultural adaptation (including screening and monitoring tools) are most helpful in implementing collaborative care for minority populations, and whether the inclusion of virtual components (e.g., telehealth) changes access to, and delivery of, care for racial/ethnic minority populations.”
The Effectiveness of Collaborative Care on Depression Outcomes for Racial/Ethnic Minority Populations in Primary Care: A Systematic Review by Jennifer Hu, MD, Tina Wu, MD, Swathi Damodaran, MD, MPH, Karen Tabb, PhD, Amy Bauer, MD, MS, FACLP, and Hsiang Huang, MD, MPH, is here.
ACLP Board director Dr. Bauer discusses integrated community care in underserved populations. See: Integrated Care for Underserved Communities, this issue.