Studies address improving care for Chinese American immigrants with depression

Two recent studies led by Massachusetts General Hospital (MGH) psychiatrists have investigated ways of improving the treatment of depression in Chinese American immigrants, a group that tends to avoid mental health treatment because of traditional cultural beliefs. One study evaluates the effectiveness of a telepsychiatry-based version of a previously developed model for culturally sensitive treatment, and the other examines the impact of stigma on the outcomes of depression treatment. Both studies have been published in the Journal of Clinical Psychiatry.

"We know that stigma tends to drive illnesses underground and leads to delays in seeking treatment, which has been demonstrated in conditions such as HIV/AIDS, substance use disorders and physical disabilities," says Justin Chen, MD, MPH, of the MGH Department of Psychiatry, who led the stigma study. "Chinese immigrants with traditional beliefs greatly stigmatize mental illnesses, often equating them with a moral defect in sufferers and fearing contagion."

To help combat the reluctance of Chinese American immigrants to seek treatment for depression, a team led by Albert Yeung, MD, ScD, also of MGH Psychiatry and the leader of the telepsychiatry study, previously developed a Culturally Sensitive Collaborative Treatment (CSCT) model that includes screening all primary care patients for depression symptoms prior to a physician visit and for those screening positive a specially designed assessment that focuses on patients' beliefs about their symptoms. The results of that assessment are used to discuss depression with patients in ways that are compatible with their beliefs.

A study led by Yeung and published in the December 2010 American Journal of Public Health described a trial of CSCT carried out at the South Cove Community Health Center, which serves Boston's Chinatown community. The study found that use of CSCT was both feasible and effective in helping patients recognize and seek treatment for depression, increasing treatment participation almost seven-fold.

For his current study, which was designed to address the scarcity of health professional with the cultural knowledge and language skills necessary to treat these patients, Yeung added a telepsychiatry component to the CSCT model. Carried out at South Cove from 2009 to 2012, the study randomized a group of 190 non-English-speaking patients who screened positive for depression to receive either usual treatment, which did not include CSCT, or a telepsychiatry-based version of CSCT.

While both groups had an initial videoconferenced interview at South Cove with a bilingual psychiatrist, the special CSCT assessment was given only to the telemedicine group. Those participants also were assigned a bilingual case manager, who monitored and consolidated their treatment and conducted regular telephone "visits" throughout the six-month study period. During those calls the care manager assessed participants' symptoms and discussed how well they were adhering to their recommended treatment and whether those taking antidepressants were experiencing any adverse side effects.

At the end of the study period, participants in the telemedicine-CSCT group had significantly greater improvement in depression symptoms than did the usual care group. "Our results show that telepsychiatry is technologically feasible and acceptable to this population," says Yeung, who is an associate professor of Psychiatry at Harvard Medical School. "Telepsychiatry could allow such services to be delivered to patients in geographically remote areas, and combining it with CSCT provides a model to overcome the limited availability of bicultural and bilingual clinicians in this country."

Chen conducted his study in the same group of patients who enrolled in Yeung's study. Among the initial assessments of both groups in the telepsychiatry study were measures of participants' illness beliefs, including questions designed to assess stigmatizing attitudes towards their own symptoms. As part of this study, all participants had bimonthly assessments conducted by telephone of depression symptoms and overall quality of life.

At the end of the six-month study period, participants who had exhibited higher levels of stigma towards their symptoms at the beginning showed less improvement in depression symptoms and in overall quality of life than did those with lower initial stigma scores. The association between baseline stigmatizing attitudes and the outcome of depression treatment was seen in both the telemedicine and the control groups of Yeung's study.

An instructor in Psychiatry at Harvard Medical School, Chen says, "Traditional Chinese communities greatly stigmatize mental illness in part due to the concept of 'face,' which reflects a person's or a family's moral standing within the community. But the effect of that stigma on actual outcomes in depression treatment has never been studied before and certainly not in minority populations. Our study suggests that stigmatizing beliefs may exert an independently harmful effect on depression outcomes. As a separate but related issue, we had hypothesized that culturally sensitive treatment might modify the effects of stigma on depression outcomes, but our results suggest that culturally sensitive diagnosis and care management alone are not enough to mitigate stigma's harmful effects."

Yeung adds, "While patients do benefit from the telepsychiatry-augmented CSCT, those with higher levels of stigma tend to do less well. Future research efforts need to include more education and demystification of mental illness to help reduce stigma, along with investigating patient characteristics that may contribute to or reduce stigma. We're also hoping to disseminate the telepsychiatry-CSCT model to different populations and to groups in various geographical locations, which will require training of mental health clinicians and care managers, education of primary care providers and the support of local primary care clinics."

The telepsychiatry study, which was published in the August issue of Journal of Clinical Psychiatry, was supported by National Institutes of Health grant RO1 MH079831.