Culture and Depression: Clinical Considerations for Racial and Ethnic Minorities

Abstract

With the current demographic shifts, the United States will soon become a “majority minority” country. US Census estimates that by 2044, the United States is projected to become a plurality nation, with no race or ethnic group projected to have a greater than a 50% share of the nation’s total population. As racial and ethnic minority groups (including Blacks, Latino Americans, and Asian Americans) continue to grow, there is a need to understand how depression affects these underserved populations. Although in some studies the prevalence of depression in racial and ethnic minorities has been found to be similar to that of whites, significant social factors such as socioeconomic status and poverty may contribute to risk for depression in these minority populations. Furthermore, significant disparities exist in depression diagnosis, access to care, and treatment, secondary to the interplay of patient-level and structural barriers (the latter defined as the systematic factors preventing access to healthcare resources and care). Interventions to better care for these populations, including clinician education and cultural competency training, have been developed. Having familiarity with the DSM-5 Outline for Cultural Formulation and the Cultural Formulation interview may allow individual clinicians to provide better care for racial and ethnic minorities with depression.

FAQs: Common Questions and Answers

• Q1. What’s the best way to approach a patient from a racial or ethnic minority background different from my own?

• A1. Realize that patients from different cultural backgrounds may have unique needs and issues that require additional time and resources. The clinical relationship will be more complex, and it will likely take longer to develop trust and alliance. Be respectful to all patients and address them formally (e.g., Mr., Ms., Mrs.), particularly early in the treatment relationship, before an alliance is well established.

• Q2. What is the best initial approach for engaging racial and ethnic minorities in psychiatric treatment?

• A2. Understand how personal biases and stereotyping may affect treatment. Beginning the initial therapeutic encounter with a minority patient, as with any patient, requires that the clinician put the patient at ease in order to develop rapport and a willingness to work together over time. Many depressed minority patients may have somatic complaints; therefore, beginning the discussion with the medical aspects of their health often is a good way to “break the ice”. That being said, racial and ethnic groups are highly heterogeneous and may include a diverse mix of individuals with different cultures, overlapping identities, languages, practices, and experiences. Be careful not to make assumptions about a patient’s values or behavior based on race, ethnicity, or culture, as such generalizations can be misleading and have harmful effects on a patient.

• Q3. How can I overcome obstacles to clinician-patient communication when treating populations of ethnic backgrounds different from my own?

• A3. Confronting challenges with communication: Assure patients about confidentiality, as it may be important due to shame, fear, or paranoia related to prior traumatic experiences. Pay attention to communication (e.g., nonverbal communication, expressive styles, and the connotations of words). Anticipate that the patient may have mistrust or fear of treatment due to prior poor experiences with healthcare systems.

• Q4. How can I address diagnostic considerations in these populations?

• A4. Considering diagnostic dilemmas: If a diagnosis is unclear or might be impacted by ethnicity or culture, consider employing a structured diagnostic interview tool (such as the Cultural Formulation Interview) to reduce the possibility of misdiagnosis. Consider interviewing patients with a bilingual, bicultural interpreter, who can facilitate the education of patients and families to reduce stigma surrounding mental illness. Consider obtaining a curbside consultation from a clinician of the relevant ethnic background (if available).

• Q5. What particular medication considerations should I keep in mind for these populations?

• A5. Considering medication choices: When encountering a patient of a particular ethnic background, one should avoid assuming every such patient will tolerate the same doses of medications. Be prepared to start with lower medication dosages and increase the dose slowly (as tolerated and as clinically indicated). In addition, be sure to ask about the use of herbal medicines, since use of these agents has increased dramatically in the United States in the past few decades. Remember that drug-herbal medicine interactions exist and should be carefully considered.

• Q6. What about including family members in treatment?

• A6. Involving family: As for all patients, providers should request consent prior to talking to and engaging family members in treatment. Both the way family members interact with one another and the family functions as a whole have a significant impact on psychiatric treatment. Many racial and ethnic minorities have a “closed network” that consists of multiple family members, kin, and intimate friends. Some may rely on interactions with relatives for social support, and some become more demoralized when such interactions do not increase with treatment. Racial and ethnic minorities may request to have members of their extended family involved in their treatment, including discussions with their providers. Family members may be able to provide collateral information and be a source of emotional and practical support for patients. In some cases, family consensus may be desired by the patient prior to engaging in a particular course of treatment, and the clinician should be attuned to such familial dynamics.

• Q7. What can I do to increase retention of racial and ethnic minorities in my practice?

• A7. Improving adherence: In addition to the tips above, focusing on practical barriers faced by patients and their families (challenges with making and keeping appointments, insurance issues, etc.) may be helpful for racial and ethnic minorities. Providers can set the tone by engaging patients and their families in conversations regarding using their preferred vocabulary (rather than medical jargon) and by focusing on the patient’s goals—which may not always overlap with our clinical focus. The use of well-trained interpreters who possess knowledge of the patient’s understanding of treatment recommendations can also significantly impact adherence. Other factors to consider regarding adherence include misdiagnosis of a psychiatric condition, a placebo response, mistrust of the healthcare system, attention seeking at a later stage of illness, and cultural beliefs and expectations regarding treatment.