BRIGHTEN Heart: Design and baseline characteristics of a randomized controlled trial for minority older adults with depression and cardiometabolic syndrome.

OBJECTIVES: African American and Hispanic elderly are at elevated risk of both depression and cardiovascular disease, relative to non-Hispanic whites. Effective interventions are therefore needed to address depressive symptoms and to reduce these disparities. BRIGHTEN Heart was a behavioral randomized controlled trial to test the efficacy of a virtual team intervention in reducing depressive symptoms in minority elderly as measured by the 9-item Patient Health Questionnaire (PHQ9). STUDY DESIGN: 250 African American and Hispanic adults, age ≥60 years, with comorbid depression and overweight/obesity were randomized. Participants randomized to the Intervention condition received a social work evaluation, team-based electronic consultation, case management, and psychotherapy over a 12 month period. Control participants were enrolled in a membership program that provided health classes and other services to support chronic disease self-management. Blinded research assistants completed assessments at baseline, and 6 and 12 months postrandomization. RESULTS: The study population was characterized by low socioeconomic status, with 81.4% having a household income of less than $20,000. Although median depression scores were in the mild range, 25% of participants had scores showing moderate to severe depression at baseline. 75% of participants had four or more chronic conditions. Significant demographic and clinical differences were observed between the African American and Hispanic populations. CONCLUSIONS: BRIGHTEN Heart was designed to rigorously test the efficacy of a multi-level intervention to reduce comorbid depressive symptoms and cardiovascular risk in minority elderly. Investigators successfully recruited a cohort well suited to testing the study hypothesis.

Cross-cultural issues in primary care medicine.

A generation ago, the experience of practicing medicine across cultural lines was far less common than it is today. In contemporary American society, the population is much more diverse in race, culture, language, religion, and ethnicity. Although health care is increasingly guided by scientific, evidence-based models, individual patients are increasingly seeking health care that addresses their personal beliefs and needs. Physicians must develop the knowledge and the skills to engage patients from different cultures and to understand the beliefs and the values of those cultures. If physicians focus only on a narrowly defined biomedical approach to the treatment of disease, they will often misunderstand their patients, miss valuable diagnostic cues, and experience higher rates of patient noncompliance with therapies. Such miscommunication will also result in greater patient dissatisfaction and more malpractice suits. This article reviews the role of culture in primary care medicine and the effect of health beliefs on decisions to seek care. Other influences, including the patient's family, language, and socioeconomic status, are examined. The possible effects of the physician's own culture are looked at as well. Methods of eliciting the patient's explanatory model are reviewed, and guidance is given on strategies to avoid miscommunication or misunderstandings. Additionally, the physician is given guidance on how to draw on the patient's beliefs and values as resources in health promotion and the treatment of disease. Specifically, the use of interpreters to overcome language barriers is reviewed. Behaviors are identified that can maximize the accuracy of communication when interpreters are needed. Physicians who actively seek to understand their patients' cultures will find their simple efforts amply rewarded by improved patient access to health care, increased patient satisfaction, and greater clinical effectiveness.

The family with a member who has cancer.

Optimal medical care for persons with chronic illnesses such as cancer cannot be provided unless the physician adopts a family-oriented approach to patient care. Such an approach requires little additional time or effort but profoundly affects the ability of patient and family to cope with cancer. Physicians should routinely gather data about the family system of their patients with cancer and make use of that data in understanding the unique issues the patient will face in adapting to their illness. The physician's goal should be to anticipate how the illness will affect the family at its current stage of the life cycle and recognize how the patient's family is currently affecting the patient's experience of the illness. The maintenance of clear, open communication among patient, family, and physician is critical to successful adaptation.