Patient-Centered Depression Care for African Americans

Several studies document underutilization of outpatient specialty mental health services by
African Americans. However, African Americans with depression are just as likely as whites
to receive care in primary care settings. Despite their use of primary care services,
African American patients are less likely than whites to be recognized as depressed, offered
pharmacotherapy, and to initiate or complete pharmacotherapy or psychotherapy for
depression. Compared to whites, African American patients express stronger preferences for
counseling and more negative attitudes toward antidepressant medication, the most common
form of treatment of depression used by primary care physicians. African Americans are also
more likely to see depression and its treatment through a spiritual or religious framework.
Studies show that African Americans receive less optimal technical and interpersonal health
care than whites for many conditions. Depression is a common chronic condition that results
in substantial morbidity, functional disability, and resource use. Despite the proven
efficacy of pharmacotherapy and psychotherapy for treatment of depression, the gap between
research findings and clinical practice is wide for management of depression in primary
care. Recent intervention work has shown that quality improvement strategies for depression
in primary care are effective. Research also shows that cultural adaptations can improve
adherence and retention in care for ethnic minority patients. We have created a
patient-centered adaptation that includes many of the components of recent successful
quality improvement interventions for depression in primary care. The proposed study
compares a standard depression intervention for patients (delivered by a depression case
manager) and physicians (review of guidelines and structured mental health consultation) to
a patient-centered intervention for patients (incorporates patient activation, individual
preferences, and cultural sensitivity) and physicians (incorporates participatory
communication skills training with individualized feedback on interactive CD-ROM). Thirty
physicians and 250 patients will be randomized to either the standard interventions or the
culturally tailored interventions. The main hypothesis is that patients in the
patient-centered, culturally tailored intervention group will have higher remission rates
from depression and lower levels of depressive symptoms at 12 months than patients in the
standard intervention care group. Secondary outcomes will include patient receipt of
guideline concordant care, patient and physician satisfaction with care, patient-physician
communication behaviors, patient and physician attitudes towards depression, and
self-efficacy in managing depression. This study will add to knowledge about how to
effectively engage African American patients in care of depression and serve as a prototype
of how to incorporate patient-centeredness in programs to reduce racial and ethnic
disparities in health care for common conditions.

Inclusion Criteria:

- Patients who have experienced two weeks or more of depressed mood/ loss of interest
in the past year

- Patients who have experienced one week or more of depressed mood or loss of interest
in the past month

- Self defined race or ethnicity African American

- Able to give written consent

Exclusion Criteria:

- Current alcohol or drug abuse

- History of mania

- Grief reaction or bereavement within the past 2 months

- Pregnancy

- Life expectancy less than 1 year

- Non English speaking

- Current specialty mental health care (at least 2 visits in past 6 weeks and appt
scheduled in future

- Plan to change health care or primary care Provider in next 12 months

- Active suicidal thoughts and plans

- Residing in US for less than 5 years