Cultural Humility and the Practice of Consultation-Liaison Psychiatry.

BACKGROUND: Cultural competency has long been the gold standard for clinicians who treat patients of different races and/or cultural backgrounds than their own. However, in recent years, there has been increasing criticism of the cultural competency framework because of its reliance on stereotypes and an overemphasis on knowledge acquisition. OBJECTIVE: We review this transition, including the critiques of cultural competency. We highlight trends in psychiatrist diversity, education, and training on cultural humility, including how consultation-liaison psychiatrists can incorporate advances in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, regarding the role of culture in clinical diagnosis, treatment, and management. METHODS: We review the transition from cultural competency to cultural humility, including the critiques of cultural competency. We highlight trends in psychiatrist diversity, education, and training on cultural humility. RESULTS: We illustrate how consultation-liaison psychiatrists can incorporate advances in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, regarding the role of culture in clinical diagnosis, treatment, and management. CONCLUSIONS: Cultural humility, which minimizes the power imbalance between clinicians and patients and emphasizes patient-focused interviewing and care, is a useful approach for consultation-liaison psychiatrists working with diverse patients and with diverse multidisciplinary teams in the general hospital.

Patient primary language in a culturally focused intervention for Latino Americans with depression.

BACKGROUND: This study examined whether a culturally focused psychiatric consultation program (CFP) for Latino Americans was equally effective in reducing depressive symptoms in English-speaking and Spanish-speaking patients. METHODS: The CFP utilizes the Engagement Interview Protocol (EIP), a semi-standardized protocol eliciting patient narratives about illness beliefs. The sample included 118 Latino American patients presenting with depressive symptoms. Patient-preferred primary language was examined as a moderator for the effect of CFP participation vs usual care on change in depressive symptoms. RESULTS: Multiple regression analysis revealed that the interaction effect of primary language and treatment arm on depressive symptoms, as measured by the Quick Inventory of Depressive Symptomatology-Self Report was not statistically significant at 6-month follow-up (B = -2.89, t = -1.35, P = .180). CONCLUSIONS: The findings suggest that the CFP was equally effective in both Spanish and English-speaking Latino Americans. The trend in the results toward greater reduction in depressive symptoms in primary Spanish-speaking Latino Americans as compared with primary English-speaking Latino Americans suggests the importance of receiving language-concordant care.

Exploring Asian American attitudes regarding mental health treatment in primary care: A qualitative study.

BACKGROUND: In this exploratory study, we examined attitudes regarding mental health treatment among 10 Asian American patients in an urban primary care setting to better understand contextual barriers to care. METHODS: Ten semi-structured telephone interviews were conducted with Asian Americans recruited from primary care practices in an urban medical center. RESULTS: The study's qualitative data suggest that focusing on specific cultural concerns is essential for increasing mental health access for Asian Americans. Although few participants initially expressed interest in a culturally focused mental health program themselves, when phrased as being part of their primary care practice, 8 expressed interest. Furthermore, most felt that the program could help family or friends. Many participants preferred to seek care initially from social systems and alternative and complementary medicine before seeking psychiatric care. CONCLUSIONS: Because Asian Americans face notable barriers to seeking mental health treatment, addressing cultural concerns by providing culturally sensitive care could help make mental health treatment more acceptable, particularly among less acculturated individuals. To our knowledge, this is the first qualitative study exploring barriers to Asian Americans accessing integrated mental health services in primary care.

Cultural Humility for Consultation-Liaison Psychiatrists.

BACKGROUND: Case presentation and analysis is a useful way to revisit key clinical themes, broad concepts, and teach others, especially when it comes to cross-cultural clinical issues. Patients from different cultural backgrounds tend to have different explanatory models of illnesses and related help seeking behaviors. Ineffective communication between clinicians and patients from nonmajority cultural groups may lead to less satisfaction with care and disparities in access to health care and in treatment outcomes. CONCLUSIONS: To address health disparities, psychiatrists need to be able to understand the illness beliefs of all patients, particularly those from diverse cultural backgrounds. Using cultural humility to work with patients from all cultures by understanding the patients' values and preferences is a key attitude for successful cross-cultural clinical encounters.

An Update on Telepsychiatry and How It Can Leverage Collaborative, Stepped, and Integrated Services to Primary Care.

INTRODUCTION: In this era of patient-centered care, telepsychiatry (TP; video or synchronous) provides quality care with outcomes as good as in-person care, facilitates access to care, and leverages a wide range of treatments at a distance. METHOD: This conceptual review article explores TP as applied to newer models of care (e.g., collaborative, stepped, and integrated care). RESULTS: The field of psychosomatic medicine (PSM) has developed clinical care models, educates interdisciplinary team members, and provides leadership to clinical teams. PSM is uniquely positioned to steer TP and implement other telebehavioral health care options (e.g., e-mail/telephone, psych/mental health apps) in the future in primary care. Together, PSM and TP provide versatility to health systems by enabling more patient points-of-entry, matching patient needs with provider skills, and helping providers work at the top of their licenses. TP and other technologies make collaborative, stepped, and integrated care less costly and more accessible. CONCLUSION: Effective health care delivery matches the intensity of the services to the needs of a patient population or clinic, standardizes interventions, and evaluates both process and clinical outcomes. More research is indicated on the application of TP and other technologies to these service delivery models.

Ketamine augmentation for outpatients with treatment-resistant depression: Preliminary evidence for two-step intravenous dose escalation.

OBJECTIVE: Preliminary evidence supports the safety and efficacy of subanesthetic ketamine as an experimental antidepressant, although its effects are often not sustained beyond one week. Studies are lacking that have examined the sustained effects of escalating ketamine doses as augmentation in outpatients with treatment-resistant depression. Therefore, the aims of this study were twofold: (1) to assess the safety and antidepressant efficacy of two-step, repeated-dose ketamine augmentation and (2) to assess the duration of ketamine's antidepressant efficacy as augmentation to ongoing antidepressant pharmacotherapy for 3 months after the final infusion. METHODS: Fourteen patients with treatment-resistant depression were eligible to receive augmentation with six open-label intravenous ketamine infusions over 3 weeks. For the first three infusions, ketamine was administered at a dose of 0.5 mg/kg over 45 minutes; the dose was increased to 0.75 mg/kg over 45 minutes for the subsequent three infusions. The primary outcome measure was response (as measured on Hamilton Depression Rating Scale-28 items). RESULTS: After the completion of three ketamine infusions, 7.1% (1/14) responded; after all six ketamine infusions, 41.7% (5/12) completers responded and 16.7% (2/12) remitted. Intent-to-treat response and remission rates at the end of the final infusion were 35.7% (5/14) and 14.3% (2/14), respectively. However, all but one responder relapsed within 2 weeks after the final infusion. CONCLUSION: Repeated, escalating doses of intravenous ketamine augmentation were preliminarily found to be feasible, efficacious and well tolerated. Interaction with concomitant medications and elevated level of treatment resistance are possible factors for non-response.

Use of the Patient Health Questionnaire-9 and a detailed suicide evaluation in determining imminent suicidality in distressed patients with cardiac disease.

BACKGROUND: The risk of suicide is elevated in patients with cardiac disease in comparison with the general population. OBJECTIVE: In distressed cardiac inpatients, we explored the use of Item 9 of the Patient Health Questionnaire-9, which inquires about thoughts of death or suicide, and a detailed suicide evaluation (DSE) triggered by positive responses to Item 9 as means of assessing suicide. METHODS: Among cardiac inpatients endorsing current emotional distress, we recorded the prevalence of positive responses to Item 9, gathered information about outcomes and time spent completing the DSE, and examined the frequency of imminent suicidality identified by the DSE among Item 9-positive patients. RESULTS: Among 366 patients, 77 (21%) answered affirmatively to Item 9. All DSEs were successfully completed but consumed 17 clinician hours. Among the 71 patients receiving the DSE, 2 (0.5% of total sample; 2.8% of Item 9-positive patients) were imminently suicidal (i.e., had intent or plan). CONCLUSION: Nearly 1 in 4 patients had a positive response to Item 9, but very few had imminent suicidality; the DSE was easy to use and acceptable to patients but time consuming. A more narrowly focused alternative to Item 9 may more accurately predict imminent suicidality and reduce the burden of further detailed suicide screening.

Treatment Outcome in Depressed Latinos Predicted by Concomitant Psychosislike Symptoms.

We compared treatment response (≥50 decrease in Nine-Item Patient Health Questionnaire total score) among 24 Latinos with major depressive disorder, presenting with and without specific psychosislike symptoms: A, hearing noises or house sounds, B, hearing voices calling one's name, C, seeing fleeting visions such as shadows, and D, symptoms more likely to be truly psychotic (e.g., poorly defined and short-lasting voices [other than B], fleeting paranoid ideation, or fleeting ideas of reference). 18 subjects (75%) endorsed symptoms of cluster A, 12 (50%) of cluster B, 10 (31%) of cluster C, and 12 (50%) of cluster D. Only subjects who reported symptoms from the D cluster exhibited significantly unfavorable depressive outcomes (compared to those with absence of D symptoms). The authors propose a phenomenological differentiation between benign psychosislike symptoms (clusters A-C) and the expression of the psychotic continuum (cluster D) in depressed Latinos.

Does use of primary care-based behavioral health programs differ by race and ethnicity? Evidence from a multi-site collaborative care model.

BACKGROUND: Collaborative care models (CoCM) that integrate mental health and primary care improve outcomes and could help address racial and ethnic mental health disparities. We examined whether use of these programs differs by race/ethnicity. METHODS: This retrospective study examined two CoCM interventions implemented across primary care clinics in a large health system in Massachusetts: 1) a primary care-based behavioral health program for depression or anxiety (IMPACT model) and 2) referral to community-based specialty care services (Resource-finding). Outcomes included enrollment, non-completion, and symptom screening rates, and discharge status for Black, Hispanic and White patients referred for CoCM, 2017-2019. RESULTS: Black and Hispanic vs. White patients referred to CoCM (n = 17,280) were more likely to live in high poverty ZIP codes (34% and 40% vs. 9%). Rates of program enrollment, non-completion, and symptom screening were similar across groups (e.g., 76%, 77%, and 75% of Black, Hispanic, and White patients enrolled). Hispanic vs. White patients were more likely to be enrolled in IMPACT (56%) vs. Resource-finding (43%). Among those completing IMPACT, Hispanic vs. White patients were more likely to be stepped to psychiatry vs. discharged to their primary care provider (51% vs. 20%, aOR = 1.55, 95% CI: 1.02-2.35). CONCLUSIONS: Black and Hispanic patients referred to CoCM were similarly likely to use the program as White patients. Hispanic patients completing IMPACT were more frequently referred to psychiatry. IMPLICATIONS: These results highlight the promise of CoCMs for engaging minority populations in mental healthcare. Hispanic patients may benefit from additional intervention or earlier linkage to specialty care.

Clinical Outcomes in Measurement-based Treatment (Comet): a trial of depression monitoring and feedback to primary care physicians.

BACKGROUND: Despite the availability of effective treatments for depression, many patients under the care of primary care physicians do not achieve remission. Clinical Outcomes in Measurement-based Treatment (COMET) was designed to assess whether communicating patient-reported depression symptom severity to primary care physicians affects patient outcomes at 6 months. METHODS: Nine hundred fifteen patients (intervention: n = 503; control: n = 412) diagnosed with major depressive disorder were enrolled in a prospective trial in which physician practice sites were assigned to either the intervention or control study arm. Only patients who were prescribed an antidepressant by their physician were eligible, but medication type was independent of the study protocol. Intervention-arm physicians received monthly updates on their patients' depression severity, which was determined with the nine-item Patient Health Questionnaire (PHQ-9) administered during telephone interviews. Remission was defined as a PHQ-9 score <5 at 6 months; response was defined as a score reduction ≥50%. RESULTS: Among patients with baseline PHQ-9 score ≥5, 45.0% achieved remission (46.7% intervention versus 42.8% control) and 63.9% responded (67.0% intervention versus 59.7% control) at 6 months. After adjusting for baseline demographic and clinical variables, odds of remission (odds ratio [OR], 1.59 [95% CI, 1.07-2.37]) or response (OR, 2.02 [95% CI, 1.36-3.02]) were significantly greater for the intervention group than for control patients. CONCLUSIONS: This study demonstrated that regular patient symptom monitoring with feedback to physicians improved outcomes of depression treatment in the primary care setting. Determining reasons for the high observed nonremission rates requires further investigation.

Cross-cultural aspects of depression management in primary care.

Major depressive disorder (MDD) is a prevalent illness in minority populations. Minority patients with MDD are often unrecognized and untreated. This review examines promising interventions to address MDD in primary care settings, where minority groups are more likely to seek care. Since 2010, eleven interventions have been developed to address patient-specific and provider-specific barriers, many of which are adaptations of the collaborative care model. Other promising interventions include cultural tailoring of the collaborative care model, as well as the addition of telepsychiatry, motivational interviewing, cultural consultation, and innovations in interpreting. Overall, collaborative care was found feasible and improved satisfaction and treatment engagement of depressed minority patients in primary care. It remains inconclusive whether these newer intervention models improve MDD treatment outcomes. Future research will be needed to establish the effectiveness of these intervention models in improving the treatment outcomes of minority populations with MDD.

A three-dimensional model of thoughts: insight into depression.

Thought processing and mood regulation are closely linked, but existing classifications of mood disorders fail to recognize the complex interplay between these two clinical dimensions. Furthermore, existing classifications fail to account for the possibility that depression might be associated with an increased frequency of self-referential thoughts that could in some circumstances be related to creativity processes. Based on recent evidence from clinical phenomenology, experimental psychology and affective neuroscience, we propose a novel comprehensive theoretical framework that incorporates thought processing and emotional valence. This new taxonomy provides insights into the clinical understanding of the spectrum of mood disorders and accounts for the possibility of increased creativity in altered mood states.

A study of the effectiveness of telepsychiatry-based culturally sensitive collaborative treatment of depressed Chinese Americans.

BACKGROUND: Chinese American patients with Major Depressive Disorder (MDD) tend to underutilize mental health services and are more likely to seek help in primary care settings than from mental health specialists. Our team has reported that Culturally Sensitive Collaborative Treatment (CSCT) is effective in improving recognition and treatment engagement of depressed Chinese Americans in primary care. The current study builds on this prior research by incorporating telemedicine technology into the CSCT model. METHODS/DESIGN: We propose a randomized controlled trial to evaluate the acceptability and effectiveness of a telepsychiatry-based culturally sensitive collaborative treatment (T-CSCT) intervention targeted toward Chinese Americans. Patients meeting the study's eligibility criteria will receive either treatment as usual or the intervention under investigation. The six-month intervention involves: 1) an initial psychiatric interview using a culturally sensitive protocol via videoconference; 2) eight scheduled phone visits with a care manager assigned to the patient, who will monitor the patient's progress, as well as medication side effects and dosage if applicable; and 3) collaboration between the patient's PCP, psychiatrist, and care manager. Outcome measures include depressive symptom severity as well as patient and PCP satisfaction with the telepsychiatry-based care management service. DISCUSSION: The study investigates the T-CSCT model, which we believe will increase the feasibility and practicality of the CSCT model by adopting telemedicine technology. We anticipate that this model will expand access to culturally competent psychiatrists fluent in patients' native languages to improve treatment of depressed minority patients in primary care settings. TRIAL REGISTRATION: NCT00854542.

A study of a culturally focused psychiatric consultation service for Asian American and Latino American primary care patients with depression.

BACKGROUND: Ethnic minorities with depression are more likely to seek mental health care through primary care providers (PCPs) than mental health specialists. However, both provider and patient-specific challenges exist. PCP-specific challenges include unfamiliarity with depressive symptom profiles in diverse patient populations, limited time to address mental health, and limited referral options for mental health care. Patient-specific challenges include stigma around mental health issues and reluctance to seek mental health treatment. To address these issues, we implemented a multi-component intervention for Asian American and Latino American primary care patients with depression at Massachusetts General Hospital (MGH). METHODS/DESIGN: We propose a randomized controlled trial to evaluate a culturally appropriate intervention to improve the diagnosis and treatment of depression in our target population. Our goals are to facilitate a) primary care providers' ability to provide appropriate, culturally informed care of depression, and b) patients' knowledge of and resources for receiving treatment for depression. Our two-year long intervention targets Asian American and Latino American adult (18 years of age or older) primary care patients at MGH screening positive for symptoms of depression. All eligible patients in the intervention arm of the study who screen positive will be offered a culturally focused psychiatric (CFP) consultation. Patients will meet with a study clinician and receive toolkits that include psychoeducational booklets, worksheets and community resources. Within two weeks of the initial consultation, patients will attend a follow-up visit with the CFP clinicians. Primary outcomes will determine the feasibility and cost associated with implementation of the service, and evaluate patient and provider satisfaction with the CFP service. Exploratory aims will describe the study population at screening, recruitment, and enrollment and identify which variables influenced patient participation in the program. DISCUSSION: The study involves an innovative yet practical intervention that builds on existing resources and strives to improve quality of care for depression for minorities. Additionally, it complements the current movement in psychiatry to enhance the treatment of depression in primary care settings. If found beneficial, the intervention will serve as a model for care of Asian American and Latino American patients.

The essential role of population health during and beyond COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic has fundamentally changed how health care systems deliver services and revealed the tenuousness of care delivery based on face-to-face office visits and fee-for-service reimbursement models. Robust population health management, fostered by value-based contract participation, integrates analytics and agile clinical programs and is adaptable to optimize outcomes and reduce risk during population-level crises. In this article, we describe how mature population health programs in a learning health system have been rapidly leveraged to address the challenges of the pandemic. Population-level data and care management have facilitated identification of demographic-based disparities and community outreach. Telemedicine and integrated behavioral health have ensured critical primary care and specialty access, and mobile health and postacute interventions have shifted site of care and optimized hospital utilization. Beyond the pandemic, population health can lead as a cornerstone of a resilient health system, better prepared to improve public health and mitigate risk in a value-based paradigm.

Low-Dose Testosterone Augmentation for Antidepressant-Resistant Major Depressive Disorder in Women: An 8-Week Randomized Placebo-Controlled Study.

OBJECTIVE: Low-dose testosterone has been shown to improve depression symptom severity, fatigue, and sexual function in small studies in women not formally diagnosed with major depressive disorder. The authors sought to determine whether adjunctive low-dose transdermal testosterone improves depression symptom severity, fatigue, and sexual function in women with antidepressant-resistant major depression. A functional MRI (fMRI) substudy examined effects on activity in the anterior cingulate cortex (ACC), a brain region important in mood regulation. METHODS: The authors conducted an 8-week randomized double-blind placebo-controlled trial of adjunctive testosterone cream in 101 women, ages 21-70, with antidepressant-resistant major depression. The primary outcome measure was depression symptom severity as assessed by the Montgomery-Åsberg Depression Rating Scale (MADRS). Secondary endpoints included fatigue, sexual function, and safety measures. The primary outcome of the fMRI substudy (N=20) was change in ACC activity. RESULTS: The participants' mean age was 47 years (SD=14) and their mean baseline MADRS score was 26.6 (SD=5.9). Eighty-seven (86%) participants completed 8 weeks of treatment. MADRS scores decreased in both study arms from baseline to week 8 (testosterone arm: from 26.8 [SD=6.3] to 15.3 [SD=9.6]; placebo arm: from 26.3 [SD=5.4] to 14.4 [SD=9.3]), with no significant difference between groups. Improvement in fatigue and sexual function did not differ between groups, nor did side effects. fMRI results showed a relationship between ACC activation and androgen levels before treatment but no difference in ACC activation with testosterone compared with placebo. CONCLUSIONS: Adjunctive transdermal testosterone, although well tolerated, was not more effective than placebo in improving symptoms of depression, fatigue, or sexual dysfunction. Imaging in a subset of participants demonstrated that testosterone did not result in greater activation of the ACC.

Longer-term open-label study of adjunctive riluzole in treatment-resistant depression.

BACKGROUND: While riluzole has been investigated for the treatment of depression, little is known about its longer-term efficacy and optimal treatment duration in treatment-resistant depression (TRD). The objective of this study is to characterize the longer-term outcome of adjunctive riluzole therapy for TRD in an open-label extension of an 8-week acute treatment trial. METHODS: The data from 66 patients with TRD who received adjunctive riluzole in a 12-week open-label extension phase were analyzed. Response rates (⩾50% reduction in the Mongomery-Asberg Depression Rating Scale [MADRS] score), relapse rates (a MADRS score of ⩾22 in patients who had previously achieved response), and adverse events were examined in patients who had achieved response at the end of the acute phase and those who had not. RESULTS: Among acute phase responders, the maintained response rate was 66.7% (8/12) and the relapse rate was 8.3% (1/12). In acute phase non-responders, the response rate was 24.1% (13/54). The most commonly reported adverse event was fatigue (9.1%). Three cases were considered serious adverse events; vomiting (n = 1), shortness of breath (n = 1), and aborted suicide attempt (n = 1). LIMITATIONS: This longer-term study was open-label and uncontrolled. The sample size was relatively small. CONCLUSIONS: Longer-term adjunctive riluzole appears relatively well tolerated and beneficial for maintaining previous response. Additionally, approximately one fourth of patients who did not respond to 8-week antidepressant treatment might respond if treated with riluzole for 12 weeks. Those findings warrant further investigation because adjunctive riluzole could represent an option for treatment of depression when standard antidepressants have failed.

Transcranial Photobiomodulation for the Treatment of Major Depressive Disorder. The ELATED-2 Pilot Trial.

Objective: Our objective was to test the antidepressant effect of transcranial photobiomodulation (t-PBM) with near-infrared (NIR) light in subjects suffering from major depressive disorder (MDD). Background: t-PBM with NIR light is a new treatment for MDD. NIR light is absorbed by mitochondria; it boosts cerebral metabolism, promotes neuroplasticity, and modulates endogenous opioids, while decreasing inflammation and oxidative stress. Materials and methods: We conducted a double-blind, sham-controlled study on the safety and efficacy [change in Hamilton Depression Rating Scale (HAM-D17) total score at end-point] of adjunct t-PBM NIR [823 nm; continuous wave (CW); 28.7 × 2 cm2; 36.2 mW/cm2; up to 65.2 J/cm2; 20-30 min/session], delivered to dorsolateral prefrontal cortex, bilaterally and simultaneously, twice a week, for 8 weeks, in subjects with MDD. Baseline observation carried forward (BOCF), last observation carried forward (LOCF), and completers analyses were performed. Results: The effect size for the antidepressant effect of t-PBM, based on change in HAM-D17 total score at end-point, was 0.90, 0.75, and 1.5 (Cohen's d), respectively for BOCF (n = 21), LOCF (n = 19), and completers (n = 13). Further, t-PBM was fairly well tolerated, with no serious adverse events. Conclusions: t-PBM with NIR light demonstrated antidepressant properties with a medium to large effect size in patients with MDD. Replication is warranted, especially in consideration of the small sample size.

Should electroconvulsive therapy be given to patients with intracranial vascular lesions?

The risk of rupture and hemorrhage of intracranial vascular lesions during electroconvulsive therapy (ECT) is currently unknown. We describe 2 cases in which ECT was discontinued because of perceptual disturbances, confusion, and the subsequent discovery of intracranial angiomas. ECT has been associated with nonconvulsive status epilepticus and prolonged altered mental status following treatment, but there has been scant documentation of side effects associated with intracranial vascular malformations. We review the literature on ECT in patients with such lesions and present 2 cases in which lesions were found in the context of perceptual disturbances and altered states of consciousness following ECT.

Association Between Stigma and Depression Outcomes Among Chinese Immigrants in a Primary Care Setting.

OBJECTIVE: Stigma has been proposed to be a major underlying factor contributing to lower rates of mental health service utilization among racial/ethnic minorities in the United States. Yet, surprisingly little research has specifically explored associations between stigma, race/ethnicity, and psychiatric morbidity. This study aims to assess the impact of stigmatizing attitudes on depression outcomes among a psychiatrically underserved, immigrant Chinese population. METHODS: Between 2009 and 2012, 190 Chinese immigrants with major depressive disorder as diagnosed by the Mini International Neuropsychiatric Interview were enrolled in a trial of culturally sensitive collaborative care for depression. Participants' self-reported stigma regarding their symptoms was assessed at study entry using the Explanatory Model Interview Catalogue, and depressive symptoms were assessed with the Hamilton Depression Rating Scale (HDRS) at baseline and follow-up. Hierarchical linear regression was used to assess the association between baseline stigma score and change in HDRS score, adjusting for potential confounders. RESULTS: Higher stigma scores at baseline were significantly associated with attenuated improvement in both HDRS score and quality of life at 6 months (P < .05 for both). CONCLUSIONS: Stigma has a directly harmful effect on depression outcomes, even after individuals have been accurately diagnosed within a culturally sensitive community health center and agreed to treatment. These results support further research into interventions targeting stigma to improve mental health outcomes among minority populations. TRIAL REGISTRATION: This study is a secondary analysis of prospectively collected data from the randomized controlled trial registered by ClinicalTrials.gov identifier: NCT00854542.