Patients who screened positive for MDD (total CB-PHQ-9 score, ≥ 10) were contacted by phone about the results of their screening and were invited to join the study. Patients who consented to join the study were scheduled to have a culturally sensitive psychiatric assessment at the health center via videoconferencing with a bilingual psychiatrist who was physically located at Massachusetts General Hospital.
The Polycom® VSXTM3000 system was installed at the health center recruitment sites and at Massachusetts General Hospital. This standards-compliant compact videoconference system provides excellent audio and video quality. The systems were connected using internet protocol or Integrated Services Digital Network (ISDN) networking. All videoconferences were encrypted using the Advanced Encryption Standard to provide security during data transmission. The transmissions were at 384 kbps with no audio delay.
In 2011, the Polycom videoconferencing systems were replaced by webcams when web-based videoconferencing became available via Skype. The web-based system was inexpensive to install and required less technical support than landlines and ISDN networking. While Skype is free, it is not HIPAA compliant for telehealth; Skype for Business technically has the sufficient encryption needed for telepsychiatry, but it is not free.
Since many Chinese immigrants had low mental health literacy and strong stigma against receiving mental health services, culturally sensitive assessment was performed using the EIP. This semi-structured instrument is designed to bridge illness beliefs of people from diverse cultural backgrounds with the psychiatric framework described by DSM. The EIP includes exploration of the patient’s narratives and illness beliefs, disclosure of the patient’s psychiatric illness in a way that is compatible with his or her illness beliefs, and negotiation of treatment of depression that is agreeable to the patient. Interviewing with the EIP allows clinicians to discuss patients’ illnesses and treatment options using language and a framework that are relevant to the context of their lives and to avoid psychiatric jargon that is unfamiliar to patients.
In the T-CSCT study, specific EIP-based questions were asked to explore illness beliefs (Table 2). With knowledge of the patient’s illness beliefs, the psychiatrist disclosed the diagnosis of depression in ways that were compatible with those beliefs and discussed treatment options.
After psychiatric assessment, patients with confirmed MDD were encouraged to seek treatment from their PCP, who received a letter about the patient’s diagnosis and a recommended treatment plan. Patients could also choose to seek treatment or consultation from a psychiatrist or a therapist.
Care managers were accessible to patients via telephone and served as a link between patients, PCPs, and consulting psychiatrists. They facilitated patients’ depression treatment and coordinated visits with psychiatrists and psychologists. A psychiatrist provided weekly supervision to care managers, as well as consultations with patients and their PCPs.
At the beginning of the study, a bilingual care manager met with patients to establish rapport, explain the role of the care manager, and provide education on MDD. After the initial meeting, the care manager contacted the patient monthly for 6 months using telephone calls to monitor the patient’s depressive symptoms, adherence to medication treatment, management of adverse events, and knowledge of self-management strategies.
T-CSCT is a promising and effective model to improve treatment of MDD for underserved racial and ethnic minority populations. We encourage future replications and testing of this approach to other racial and minority groups with diverse cultural backgrounds who suffer from disparities in depression treatment.
Dr. Yeung is Associate Professor of Psychiatry, Harvard Medical School, Boston, MA. Dr. Yeung reports no conflicts of interest concerning the subject matter of this article.
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