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4 Steps to Improve Depression Care for Multicultural Communities

Analysis  |  By Christopher Cheney  
   January 24, 2019

Multicultural patients face multiple barriers to receiving care for depression such as scant referral options.

A Virginia-based health center's quality improvement project was able to significantly improve depression care for a vulnerable multicultural population, research shows.

Annual societal costs associated with depression are estimated at $210 billion, and depression is the top cause of disability globally. For minority, immigrant, or refugee patients, cultural factors often impede on depression treatment such as confusion about the concept "warm handoff."

Depression screening is a building block for behavioral health interventions, the lead author of the research, Ann Schaeffer, DNP, a certified nurse midwife at Harrisonburg Community Health Center (HCHC) in Virginia, told HealthLeaders.

"Improving depression screening should lead to measurable outcomes for those who screen positive, including referral to mental health specialists, prescription of appropriate medications, and perhaps most importantly, scheduling of follow-up appointments to monitor signs and symptoms of depression," she said.

At HCHC, an effort was launched to boost access to depression services in vulnerable multicultural communities, Schaeffer said.

"There are multiple barriers. These include clinics not prepared with screening tools in multiple languages; providers not culturally aware of the stigma attached to depression; lack of provider confidence in client engagement; and few referral options for multicultural populations," she said.

The HCHC initiative made significant progress. Evidence-based care practice increased to 71.4%, adherence to follow-up care increased from 33.3% to 60.0%., and the rate of screening in patients' preferred language increased to 85.2%.

To topple barriers to care, HCHC implemented a four-part intervention.

1. Utilizing multilingual screening

With the Patient Health Questionnaire in six languages as the screening instrument, any score other than zero was considered positive and led to a brief intervention and follow-up planning.

The PHQ, which features nine questions, was made available to patients in English, Spanish, Arabic, Russian, Kurdish, Swahili, and Tigrinya.

2. Sharing decision-making

After a patient screened positive, the care team used the Option Grid shared decision-making tool to guide the conversation about follow-up care. The Option Grid was translated into the top three languages in the patient population: Arabic, English, and Spanish.

Option Grid features standardized tools to help patients share what matters most to them, are easy to read, are simple to use, and meet shared decision-making standards.

3. Engaging with patients

HCHC used a tracking log that monitored weekly follow-up calls, behavioral health appointments, and handoffs to social workers in primary care practices.

The tracking log had several other elements.

  • A checklist of seven depression risk factors such as chronic illness and abuse
  • A nine-point checklist for plan of care, including education, watchful waiting, and medication
  • Choice of follow up—appointment, phone call, or none
  • Outcome of follow-up care and plan for future care
  • Tracking of PHQ scores, which were collected at all patient follow-up visits

4. Building strong team

HCHC held team meetings every two weeks to focus on education, training, capacity building, and communicating about the initiative.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


Annual societal costs linked to depression are estimated at $210 billion.

Language and cultural differences contribute to low treatment rates for depression in culturally diverse communities.

Screening is foundational in depression care.

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