Cultural Considerations in Screening and Detection

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Ethnic/Racial Differences in Depression among U.S. Primary Care Patients: Cultural Considerations in Screening and Detection a

La Tonya Noël & Arthur L. Whaley

b

a

College of Social Work, Florida State University, Tallahassee, Florida, USA b

Department of Psychology, Texas Southern University, Houston, Texas, USA Published online: 20 Nov 2012.

To cite this article: La Tonya Noël & Arthur L. Whaley (2012): Ethnic/Racial Differences in Depression among U.S. Primary Care Patients: Cultural Considerations in Screening and Detection, Journal of Ethnic And Cultural Diversity in Social Work, 21:4, 314-330 To link to this article: http://dx.doi.org/10.1080/15313204.2012.729180

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Journal of Ethnic & Cultural Diversity in Social Work, 21:314–330, 2012 Copyright © Taylor & Francis Group, LLC ISSN: 1531-3204 print/1531-3212 online DOI: 10.1080/15313204.2012.729180

Ethnic/Racial Differences in Depression among U.S. Primary Care Patients: Cultural Considerations in Screening and Detection LA TONYA NOËL Downloaded by [Florida State University] at 06:09 28 June 2013

College of Social Work, Florida State University, Tallahassee, Florida, USA

ARTHUR L. WHALEY Department of Psychology, Texas Southern University, Houston, Texas, USA

Screening and detection are essential building blocks for prevention and early treatment of depression. Despite their critical role in early identification and treatment, primary care physicians fail to recognize depression in about half of their patients. Because depressed patients of color tend to seek treatment in primary care settings, the need for greater attention to, and understanding of, ethnic and racial disparities in general practitioners’ ability to detect cases of depression is compelling. The purpose of this article is to discuss the screening and detection of depression among patients from different U.S. ethnic/racial and cultural groups. Specifically, the objective is to identify withinand between-culture factors that may impact on symptom presentation for African-Americans, Asians, Hispanic/Latinos, and Native Americans, and subsequently on the diagnosis of depression in primary care settings. Implications for the role of allied health professionals, especially social workers, in enhancing the cultural competence of primary care doctors are discussed. KEYWORDS cultural bias, depression, ethnicity/race, primary care, screening and detection

This project was supported by a predoctoral fellowship from the Hogg Foundation for Mental Health to the first author. We express our appreciation to Dr. King Davis, whose tenure as the executive director of the Hogg Foundation made this project possible. Address correspondence to La Tonya Noël, PhD, College of Social Work, The Florida State University, 296 Champions Way, Tallahassee, FL 32306, USA. E-mail: [email protected] 314

Ethnic/Racial Differences in Depression

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INTRODUCTION Screening and detection are essential building blocks for prevention and early treatment of depression. They are necessary, but not sufficient, components of any effective treatment trajectory (Tiemens, Ormel, & Simon, 1996). If a patient’s depression is not recognized early by a provider, the chances of that individual receiving appropriate care are reduced. The majority of people with common mental health problems have been found to be treated mainly in primary care settings (Borowsky et al., 2001; Goldman, Nielsen, & Champion, 1999). Several scholars (Brown, Abe-Kim, & Barrio, 2003; Brown & Schulberg, 1998; Leong & Lau, 2001) assert that this is especially true of depressed ethnic/racial minority patients, who rarely seek treatment at specialty mental health clinics. This pattern of help seeking has disproportionately placed the burden of early detection of depression on primary care physicians. Despite the critical role that early identification and treatment plays in depression outcomes, primary care physicians fail to recognize depression in about half of their patients, with estimates ranging from 25% to 75% depending on the criteria used to establish the diagnosis (Berardi et al., 2005; Brody et al., 1998; Carney et al., 1999; Coyne, Schwenk, & FechnerBates, 1995; Goldberg, 1995; Perez-Stable, Miranda, Munoz, & Ying, 1990; Schulberg, Magruder, & deGruy, 1996; Simon & Von Korff, 1995). When physicians do identify patients as having depression, they are frequently wrong in their assessment, with false-positive rates ranging from 40% to 60% (Boland et al., 1996; Leo et al., 1998). The factors contributing to such a high false-positive rate have yet to be fully explored. However, Borowsky and colleagues (2001) described several factors related to the nature of the patients’ illnesses, sociodemographics, gender, and cultural background as reasons that affect physicians’ ability to recognize depression. Primary care physicians are more likely to detect depression when the patient’s symptoms are severe, accompanied by anxiety disorder or hypochondriasis, or comorbid with serious medical illness (Borowsky et al., 2001; Schulberg et al., 1996). Primary care physicians are less likely to detect psychological disorders in patients presenting with somatic symptoms, and who are unwilling to discuss their psychosocial difficulties (Kirmayer, 2001; Kirmayer, Robbins, Dworkind, & Yaffe, 1993). The patient’s gender, age, socioeconomic status, and level of education are additional factors that may impact case detection. Physicians are better at detecting depression in women than in men (Schulberg et al., 1996); in middle-aged patients than in young adults or the elderly (Borowsky et al., 2001; Harman, Schulberg, Mulsant, & Reynolds, 2001; Schulberg et al., 1996); and in patients with lower incomes and less education (Borowsky et al., 2001). Ethnicity and race also impact on the screening and detection of depression in the primary care setting.


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Researchers have also demonstrated that physicians and allied health professionals are less likely to detect depression when providers’ cultural backgrounds differ from those of their patients (Goldman et al., 1999). Moreover, both Borowsky and colleagues (2001) and Harman and colleagues (2001) found, regardless of physicians’ ethnicity, primary care doctors are less likely to detect depression in African-American and Latino patients than in European-American patients. Taken together, these findings suggest that physicians, in general, and European-American physicians in particular, may have greater trouble detecting depression in patients of different ethnic/racial backgrounds. Given that patients of color are less likely to have their depression diagnosed in the primary care setting, it is also more likely that they will receive inappropriate care. Because depressed patients of color tend to seek their mental health treatment in the primary care setting, the need for greater attention to, and understanding of, ethnic and racial disparities in general practitioners’ ability to detect cases of depression is compelling. Increased demand for detection and treatment, coupled with the incidence of under-recognition and suboptimal treatment of depression in the primary care setting, has caused primary care physicians to seek new ways to improve their capacity to recognize and treat depression (Levine et al., 2005). Collaborative care models have become the gold standard for optimally detecting and treating mental health problems among patient populations in primary care settings (Unützer et al., 2001). Collaborative care involves integrating behavioral/mental health professionals (e.g., licensed clinical social workers) into the primary care process of treating mental disorders. The process of integrating mental health service providers into primary care has been shown to be both feasible and effective (Blount, 1998; Bray, Frank, McDaniel, & Heldring, 2004). A major goal of collaborative models of care is to provide quality depression care treatment through provider education, patient activation, treatment monitoring, and access to behavioral health providers within the system of general medical care. These models provide closer follow-up of treatment outcomes; side effects and treatment adherence tracking; and use of depression measurement tools such as the Patient Health Questionnaire-9 (PHQ-9) to measure improvement. These models also often utilize an electronic depression registry to facilitate caseload supervision of depression care managers (i.e., mental health professionals) and recommendations about changes in antidepressant medication; and stepped-care approaches that provide incremental increases in treatment for patients with persistent depressive symptoms (Von Korff, Eaton, Unützer, Wells, & Wagner, 2001). Research has supported this model of care as an effective way of treating and managing depression in a variety of primary care patient populations (Katon et al., 1996, 1999, 2001, 2004; Unützer et al., 2001; Williams et al., 2007). However, if collaborative care team members (e.g., physician, social worker, or psychiatrist) are not culturally



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competent, the ability to recognize depression in patients of color is still compromised. The purpose of this article is to discuss the literature on the screening and detection of depression among patients from different ethnic/racial and cultural groups. Specifically, the objective is to identify cultural factors that may impact symptom presentation, and subsequently the diagnosis of depression in primary care settings. Both between-group and withingroup relativity of presentation in depressive symptoms will be the focus of this article. Between-group relativity refers to cultural differences that are unique to ethnic/racial groups compared to others, and within-group relativity refers to individual differences (e.g., age) within a given ethnic/racial group. In particular, this article is divided into three sections. The issue of the interplay between individual differences and cultural differences is addressed in the first section. Specific features of symptom manifestation for African-Americans, Asians, Hispanic/Latinos, and Native Americans will be elucidated in the second section. Finally, implications for the role of allied health professionals, especially social workers, in enhancing the cultural competence of primary care doctors will be discussed.

LITERATURE REVIEW Cultural Patterns versus Individual Differences The way in which ethnic/racial groups label an illness has a direct impact on how members will express symptoms and seek help (Leong & Lau, 2001). Understanding cultural variations in symptom presentation is important, but it is not the only condition necessary for the accurate diagnosis of individual members of different ethnic/racial groups. In fact, the Mental Health: Culture, Race, and Ethnicity supplemental report from the U.S. Surgeon General (1999) cautions against the generalizing from the ethnic and cultural characteristics of a known group to any given individual “based on their appearance or affiliation.” Any diagnosis given to a patient based on such broad categorizations or indiscriminate likelihoods is stereotyping and often will lead to a misdiagnosis of the patient’s condition (Harris, 2004; U.S. Surgeon General, 1999). Individual-level factors can also contribute to the onset, duration, and recurrence of depression, as well as impact on how ethnic/racial group members express depressive symptoms. Yet, sole dependence on the individual-level factors without consideration or understanding of the patient’s ethnic or cultural background can also lead to considerable misunderstandings of the patient’s symptoms and expressions of distress. In essence, it is important to see and treat the patient as a whole person; taking into consideration both his or her ethnic/racial group membership (between-group relativity) and any relevant individual-level factors (withingroup relativity) that may be contributing to the presenting symptoms

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(Brown et al., 2003). This article will outline some of the ways that different ethnic/racial groups manifest depression. Thus in the discussion of each ethnic/racial group, this article also delineates how demographic variables such as age, gender, acculturation, language, and socioeconomic status create differences in the symptom presentations of depression within a particular ethnic/racial or cultural group.


Cultural Differences in the Expression of Depression While certain universal patterns of expressing depression (e.g., disturbance in sleep patterns, fatigue, changes in appetite, weight gain or loss, reduced ability to concentrate and focus) are emphasized in commonly used diagnostic tools (e.g., Diagnostic and Statistical Manual of Mental Disorders [DSM-IV] and the International Classification of Diseases and Related Mental Health Problems [ICD-10]) (Ballenger et al., 2001), there may be differences in symptom presentations across different ethnic/racial groups that are essential to the detection of depressive disorders in members of these groups (Adebimpe, 1981; Adebimpe, Hedlund, Cho, & Wood, 1982; Brown, Schulberg, & Madonia, 1996; Jackson-Triche et al., 2000). Related to this notion, misdiagnosis among populations of color may be due largely to ethnic differences in the symptoms of depression that do not fit neatly into the Western syndrome of “depression.” Some of the cultural differences associated with the four U.S. groups of color are highlighted in the following subsections. The following discussion is meant to be illustrative rather than exhaustive in demonstrating the importance of culture for the detection and screening for depression in these ethnic/racial groups.

METHODS First, an American Psychological Association (APA) PsycNET electronic database search was performed which combined several smaller search engines (PsycINFO, PsycCRITIQUES, and PsycARTICLES) to assemble a pool of studies on expression of depression across different cultural groups. Search strategies were developed using combinations of the following keywords/index terms: depress∗ , expression of depression, depression presentation, African American, Latin∗ , Hispanic, Asian, White, Non-Hispanic White, primary care, physician, doctor, medical provider, collaborative care, cultural difference, and cultural comparison. Retrievals were reviewed by title and abstract to identify studies appearing to qualify for the review, and final decision for inclusion was based on the full report. Next, a second electronic database search was performed using ProQuest which combined several smaller search engines (social science abstracts and sociological


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abstracts). The same search terms were used for both searches. The following selection criteria were used for the articles included in the analysis: samples comprising adult patients with a depressive disorder measured by a depression measure.

FINDINGS


African-Americans African-Americans have a long history in the physical health and mental health literature as the primary comparison group to non-Hispanic whites. This group, like most other ethnic/racial groups, has diverse cultural identities that make it difficult to generalize findings. Expressions of depression may vary within this group across gender, age, geographic location, etc. However, research literature has found that, on average, African-Americans are likely to have poorer health and mental health outcomes than nonHispanic whites (Williams, Yu, Jackson, & Anderson, 1997). Consistent with this pattern, Adebimpe (1981) and Whaley (1998), among others, have also argued that depression is more often misdiagnosed among AfricanAmericans than their European-American counterparts. African-American depressed patients in the United States have been reported to exhibit more worry, somatic complaints, and physical functioning impairments (Ayalon & Young, 2003; Adebimpe, 1981; Brown et al., 1996). Typical symptoms that have been found to be related to depression in African-American primary care patients are medically unexplained complaints of pain or numbness in the patient’s chest, neck, head, arms, and stomach. Other symptoms associated with depression in African-Americans are suspiciousness, paranoia, agitation, hostility, and aggression (Adebimpe et al., 1982; Fabrega, Mezzich, & Ulrich, 1988; Whaley, 1998). Because these other symptoms are associated with different disorders, their presence as a symptom of depression in African-Americans is often overlooked or undetected. For example, even though paranoid symptoms are often linked to schizophrenia, they can often reflect an underlying depression (Combs et al., 2006; Zigler & Glick, 1988). Whaley (2001) suggested that it may be the case that paranoia is more likely to be symptomatic of depression in African-Americans than their European-American counterparts. Gender, age, and socioeconomic status have also been found to be related to differences in the presentation of depression among AfricanAmericans (Cayleff, 1988; Nations, Camino, & Walker, 1988; Sachs-Ericsson, Plant, & Blazer, 2005; Williams, Takeuchi, & Adair, 1992). Depressed African-American women have been found to attribute or explain symptoms of depression in terms related to their “nerves” (Cayleff, 1988; Nations et al., 1988). This description of “nerves” has also been associated with sleeping problems, motivation, and increased appetite as well

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as affective symptoms such as crying, yelling, anger, and poor concentration in this group (Hauenstein, 2003; Nations et al., 1988). To our knowledge, comparable data on these symptoms of depression do not exist for AfricanAmerican men. Unless primary care doctors and allied health professionals are aware of these cultural and individual-level differences in depressive symptoms among African-American patients, they are at increased risk for misdiagnosing the condition.


Asians Asians account for more than 50% of the Earth’s population. As is true for most ethnic/racial groups, there is enormous variability among persons of Asian descent with more than 25 ethnic subgroups. Distressed Asian-American patients have been found to report psychological symptoms, but somatic symptoms have been most often associated with this group (Kleinman, 1982; Yeung, Chang, Gresham, Nierenberg, & Fava, 2004). While diagnoses such as “neurasthenia,” hwabyung, or shenjing shuairo are not common in the United States, reports of these conditions often occur within the Chinese, Korean, and Japanese cultures, respectively. These culturebound syndromes signify spiritual imbalance, nerve weakness, or degenerating nerves (shenjing shuairo); anger, resentment, somatic illness, and neurotic symptoms (hwabyung); and fatigue, anxiety, headache, impotence, and neuralgia (neurasthenia). These culture-bound syndromes have also been empirically linked to classic symptoms of depression based on using both DSM and ICD criteria (Cheng, 1989; Kleinman, 1982; Kim, 2002; Lee & Wong, 1995; Pang, 2000; Yan, 1989; Zhang, 1989). For instance, researchers have found that some 40% to 90% of patients diagnosed as having neurasthenia actually met the criteria for depression and showed marked improvement when treated with antidepressants (Kleinman, 1982). Because the description and diagnosis of neurasthenia is a common part of the Chinese culture, Chinese-American primary care patients may also tend to explain or describe their symptoms of depression as being neurasthenic in nature. Within-group differences in manifestations of depression have been observed in relation to level of acculturation, age, and language among Asians. For instance, several studies revealed that less acculturated Asians tend to endorse somatic symptoms over affective symptoms (Kim, 2002; Maeno, Kizawa, Ueno, Nakata, & Sato, 2002; Pang, 2000), but when further questioned even these patients will acknowledge psychological dimensions of their depression (Kleinman, 1982). An important point here is that AsianAmerican patients should not be stereotyped as being unable to express the psychological dimension of depression. Ying and colleagues (2000) demonstrated that more acculturated Chinese-Americans and U.S.-born Chinese students have a greater tendency to express symptoms of depression similar to non-Hispanic whites than less acculturated and immigrant


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Chinese-Americans. Symptom presentation of older Asian-Americans, related to language barriers and physical isolation, is commonplace. Specifically, empirical evidence suggests that older monolingual Asians are more likely to display expressions of depression from their homeland, compared to older Asians who are more acculturated with bilingual abilities (Diwan, Jonnalagadda, & Gupta, 2004). Because no research has compared the symptoms of monolingual younger Asians to older monolingual Asians, it is unclear whether this finding is due primarily to acculturation or age. What is evident from such findings, however, is that both cultural and individual-level factors influence Asians’ experience of depression.


Hispanics/Latinos Hispanic/Latino communities are diverse in language, geographic location, and spiritual beliefs and much of the available Hispanic research is based on early anthropological investigations of selected communities that are not necessarily representative of the varied Hispanic/Latino communities in the United States. However, the available research suggests that patients of Hispanic/Latino descent are likely to express their symptoms of depression in somatic complaints (Escobar, Rubio-Stipec, Canino, & Karno, 1989). Similar to African-Americans, these symptoms may include medically unexplained trembling, heart palpitations, paralysis, fainting, numbness or tingling, chest pains, dizziness, and difficulty breathing (Guarnaccia, Canino, Rubio-Stipec, & Bravo, 1993). Depressed Latino subgroups may also complain or express experiences of having little to no emotional control, emotional exploding, inability to cope, excessive worrying and jittery (onthe-edge) feelings (Guarnaccia et al., 1993). Both sets of these symptoms have also been described as the Latino syndrome nervios or sustos (Jenkins, 1997; Lopez & Hernandez, 1997; Salman et al., 1998). These culture-bound syndromes may also reflect an underlying depression. However, these effects may be confounded by language given that individuals may choose to be interviewed in English only, Spanish only, or an English-Spanish bilingual interview. When Latino individuals give responses in two languages (English and their native Spanish), they have a tendency to give culturally relevant responses in the native language and socially desirable answers in the second language (Marin, Triandis, Betancourt, & Kashima, 1983). Difficulty communicating in the non-native language could prompt greater caution and control over their emotions (Del Castillo, 1970; Marin et al., 1983). The combination of language and socioeconomic status is likely to mediate the symptom presentations of depression among some Latino groups (Taylor, Szatmari, Boyle, & Offord, 1996). For instance, Ortiz and Arce (1984) found, in a national sample of Latinos, a relationship between symptom expressions of depression and language of the interview were highly correlated with socioeconomic status (SES). In this study,

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lower-SES Latinos reported somatic symptoms when interviewed in Spanish; whereas, middle-class Latinos reported more somatic symptoms of depression when interviewed in English. Again, level of acculturation, language use, and ethnic subgroup variation appear to influence the manifestation of depression.


Native Americans Native Americans, like Asian and Latino groups, are diverse in culture, which makes it very difficult to treat this group as a single cultural population. As with the other ethnic groups, often within-group differences among Native Americans may vary more than between-group differences in comparisons with other ethnic/racial groups. In general, Native Americans view their symptoms of depression in terms of spiritual harmony and tribal connectedness (geographical and emotional). In a case study with a Native American male from a Montana tribe, O’Nell (1998) noted that he describes his depressive symptoms in an acculturated way. The interviewee stated that he has “low energy, complete loss of interest in fishing or basketball, trouble falling asleep, loss of appetite, and recurrent thoughts of death by suicide” (p. 124). However, he also expressed several culturally relevant indicators in his symptoms of depression, particularly related to his isolation from his tribal family (O’Nell, 1998). Johnson and Johnson (1965) also described a syndrome of “totally discouraged” among Sioux Indians. The symptoms of this syndrome overlap with symptoms of clinical depression and encompass feelings of helplessness and thoughts of death, but also include a preoccupation with being haunted by spirits and ghosts. It is important for this latter symptom not to be misconstrued as psychosis. In addition, and similar to African-Americans, Johnson and Cameron (2001) pointed out that the longstanding history with the U.S. government may cause many Native Americans to exhibit signs of paranoia and lack of trust, especially with individuals they view as representing institutional sources of care. Native Americans report symptoms of depression that can be classified as creating impairment in both mind and the physical body. Descriptions of anger, agitation, loss of libido, sinfulness (related to spiritual harmony), shame, not being liked, sadness, suicidal ideation, and loneliness or social isolation are all symptoms found to be associated with depression in Native Americans (O’Nell, 1989). For many Native Americans, isolation, whether emotional or geographical, has the potential to cause symptoms of depression. However, it is important to identify why an individual of Native American descent is experiencing isolation. Native Americans may also evidence age differences in symptom presentation of depression. Age appears to have a significant impact on how symptoms of depression will be expressed among Native American groups. Teenagers and young adults have been found to demonstrate more anger as


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an expression of depression than older age groups (LeMaster, Beals, Novins, Manson, & the AI-SUPERPFP Team, 2004; O’Nell, 1989). In fact, younger Native Americans are more likely to openly express symptoms of depression, whereas any focus on individual distress or misfortune among older Native Americans is considered a sign of “immaturity” and typically precludes them from expressing any symptoms of depression (O’Nell, 1989; Rieckmann et al., 2004; Whitbeck, McMorris, Hoyt, Stubben, & LaFromboise,2002). Thus cultural traditions play a significant role in the expression of depression among Native Americans in terms of lack of tribal connection leading to social isolation or cultural sanctions with age differences in the expression of volatile symptoms.

CONCLUSION Summary and Recommendations Although the research literature is limited, it is important to acknowledge that ethnicity/race and culture have an impact on symptom presentation of depression among patients seeking services in primary care settings. This article included information based on the lessons learned from the mental health specialty sector with research on cultural variation in studies of primary care patients. However, evaluating cultural variation alone leaves many unanswered questions. It also is important to consider environmental and other social conditions (e.g., SES) in combination with ethnicity and culture in order to fully understand the symptoms of depression for any given primary care patient. Moreover, individual-level factors such as age, gender, level of acculturation, and English-language proficiency should also be considered in screening and detection of depression among different ethnic/racial or cultural groups in primary care. Primary care physicians and other allied health professionals need to understand cultural influences on the physical and verbal expressions of depression across different ethnic/racial or cultural groups. Such cultural knowledge will increase their understanding of what treatment regimen patients of certain ethnic/racial groups are likely to adhere to, and will likely improve depression care outcomes. It is also necessary to develop and improve upon case management services for depressed patients, with a particular focus on maintaining disease management registries that include depression and incorporate reminders to ensure active follow-up of depressed patients (Von Korff et al., 2001). Follow-up is essential, regardless of the treatment method utilized; otherwise effective screening and detection of depression is futile. More research is needed to better understand which detection tools are most effective with patients of color in the primary medical setting. In addition, research investigating how collaborative care models might improve depression treatment outcomes for populations of color is also needed.


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Finally, there may be something unique about individuals who seek mental health services in the primary care setting. For instance, primary care patients may have a tendency to somatize complaints, rather than psychologize their symptoms, in the presentation of depression. This appeared to be the case across ethnic/racial and cultural groups presented in this review. This may be the reason that they have a tendency also to seek services from physicians in the primary care setting instead of the specialty mental health sector. Research is needed to evaluate symptom expression of depression in primary care versus mental health specialty settings. Regardless of ethnicity/race or culture, certain issues should be explored with any patient with unexplained physical symptoms or suspected cases of depression. First, it may be helpful to consider depression as a primary illness and treat the condition as such. Next, physicians and other allied health workers developing treatment plans should be sure to address issues of financial stability, current and past employment history, cultural understandings of depressive symptoms, and any psychosocial stressors that may be present in patients of color. These universal considerations in the manifestation of depressive illnesses are equally important.

Implications for the Allied Health Professions Allied health professions have an important role in addressing the cultural biases that prevent the accurate screening and detection of depression among ethnic/racial or cultural groups in primary care settings. The fact that the collaborative care model is the treatment approach of choice for mental health problems in primary care supports this assertion (Unützer et al., 2001; Von Korff et al., 2001). This includes nursing, psychology, social work, and others. In particular, social workers are often the first contact for patients during psychosocial intake and assessments. Social work is gaining ground in the delivery of primary health care in both the United States and the United Kingdom (Firth, Dyer, Marsden, Savage, & Mohamad, 2004; McLeod, 2002; Sommers, Marton, Barbaccia, & Randolph, 2000; Zayas & Dyche, 1992). Moreover, there is empirical evidence that collaborative teams in primary care including social workers improve patient outcomes (Firth et al., 2004; Sommers et al., 2000). Social workers in primary care settings should undergo cultural diversity training to acquire the needed expertise. Cultural competence may reduce cultural bias. Cultural competence is defined as a set of problem-solving skills including recognition and understanding of the heritage and adaptational dimensions of culture; knowledge of individuals’ heritage and adaptational challenges to maximize the effectiveness of assessment, diagnosis, and treatment; and internalization of this process of recognition, acquisition, and use of cultural dynamics with diverse groups (Whaley & Davis, 2007). Consideration of differences in



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the manifestation of depression between and within cultures may improve physicians’ and allied health professionals’ ability to detect and treat depression in patients from various ethnic/racial groups (Brown et al., 2003). They will then be in a position to both recognize cultural variations in symptoms of depression among primary care patients from different ethnic/racial groups, as well as provide training for primary care physicians in how to address these factors in their diagnosis and treatment regimens. Zayas and Dyche (1992) describe a training program for primary care physicians provided by social workers. Although social work has a natural connection to issues of cultural diversity, the development of culturally competent services requires more than their generic training provides. However, they could be leaders in providing training and implementing a cultural competence curriculum for primary care physicians. One example of such a curriculum in the United States has been developed by Carrillo, Green, and Betancourt (1999). This curriculum incorporates five modules which encompass a set of concepts and skills taught across different themes (module 1: basic cultural concepts; module 2: core cultural issues; module 3: understanding and exploring the meaning of the illness; module 4: determining the patient’s social context of the illness; module 5: negotiating across cultures). Each of the modules in this curriculum builds upon on one another and the modules are taught over four two-hour sessions. In addition, Firth and colleagues (2004) pointed out that the social workers’ involvement in the delivery of primary care services can be both direct and indirect. This distinction could also be applied to the promotion of cultural competence in primary care settings. Social workers can impart cultural expertise both as leaders in medical training and as participants on collaborative treatment teams. The improvements in patient outcomes associated with social workers on collaborative teams could be further enhanced by their developing cultural expertise to accurately screen and detect depression among primary care patients. However, for social workers to be able to play an active and informed roll in collaborative care management of depression in primary care settings, they will need to be trained in collaborative approaches on collaborative teams. This training may require social work programs and schools of medicine to collaborate in educational training courses and internships that would allow medical students and social workers to work together. Minimally, it requires social work programs to incorporate primary care social work courses within the generalist model of training in graduate school, so all students could gain the needed behavioral medicine and chronic illness management skills, tools, training, and attitudes that mental health professionals need to be effective in primary care (Fildes & Cooper, 2003). This training prepares clinical social workers to move beyond specialty mental health care into collaborative health care, as well as address the fragmentation of health and mental health services that has historically dominated approaches to care.

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