Increasing Access to Mental Health Services and Assessing Help-Seeking Behavior of Depressed Chinese-American Patients in Primary Care – A Feasibility Pilot Study

Background and Purpose: Chinese Americans severely underutilize mental health services, with a tendency to use mental health services as a last resort. A collaborative care management model has been advocated to advance treatment of depression in a primary care setting. The purposes of the study are to evaluate the feasibility and efficacy of care coordination between a primary care physician and a care manager, as compared with depression care by a primary care physician only, in the treatment of depression, and to understand the effects of health beliefs and perceptions such as conceptualization and labeling of depression, stigmatization, and patients' perceived barriers, on help-seeking behaviors among Chinese-Americans.

Methods: A total of 6,065 patients were screened for depression. Of 341 who screened positive (5.6%), 189 (55%) refused to participate in the study. Only 57 of them (17%) agreed to participate and they were randomly assigned to either the collaborative care group or to the enhanced usual care group. All enrolled participants were assessed at baseline and 4 monthly follow-up visits for depression, physical and mental health functioning, quality of life, and perceived stigma toward receiving mental health care, to determine the impact, if any, their mental health treatment had. Because of the high refusal rate, those who refused to enroll in the depression study were invited to participate in a separate study (refusal study) to discern factors attributing to their refusal. A semi-structured questionnaire, consisting of established psychological measures and open-ended questions adapted from the Explanatory Model Interview Catalogue, was used to assess their depression and stagnation symptoms, functional status, patterns of distress, perceived causes of difficulties, general illness beliefs, help seeking patterns, and barriers to receiving treatment.

Results: Both collaborative care (32 participants) and enhanced usual care (25 participants) groups reported significant reduction of depressive symptoms and improved mental health functioning from baseline to follow up assessments although there was no significant difference between two groups. Majority of participants indicated mild stigma toward receiving mental health care and both groups reported a high level of satisfaction with their depression care. Forty-two Chinese patients participated in the refusal study. Major themes that emerged from this study included: (a) social meaning of depression and somatization; (b) reasons and barriers to receiving mental health treatment; (c) the role of significant others in help seeking. Care utilization appears to be complicated by somatization of emotional problems, variations in causal attribution to depression and the burden of co-morbid physical conditions.

Conclusion and Implications: Barriers to participation in mental health treatment among Chinese patients are multi-factorial ranging from cultural, attitudinal to practice concerns inherent in low-income immigrant population. The collaborative care management model appears to be feasible for treating depression for Chinese Americans in a primary care setting. The study findings suggest the need to increase the ability of primary care physicians to recognize patient's perceived needs and expected benefits from mental health treatment and develop psycho-educational and motivational strategies to effectively address these issues and educate patients about the mind-body dialectic common in depression.