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BackgroundPatients with language barriers suffer significant health disparities, including adverse events and poor health outcomes. While remote language services can help improve language access, these modalities remain persistently underused. The objective of this study was to understand clinician experiences and challenges using dual-handset interpreter telephones and to inform recommendations for future language access interventions.MethodsWe conducted four focus groups with nurses (N=14) and resident physicians (N=20) to understand attitudes toward dual-handset interpreter telephones in the hospital, including general impressions, effects on communication, situations in which they did and did not use them, and impact on clinical care. Three researchers independently coded all transcripts using a constant comparative approach, meeting repeatedly to discuss coding and to reconcile differences to reach consensus.ResultsWe identified five salient themes, including increased language access (improved convenience, flexibility, and versatility of phones over in-person or ad hoc interpreters); effects on interpersonal processes of care (improved ability to communicate directly with patients); effects on clinical processes of care (improvements in critical patient care functions, including pain and medication management); impact on time (needing extra time for interpreted encounters and perceived delays impacting future use); and patients for whom, and circumstances in which, the dual-handset interpreter telephone is inadequate (e.g., complex discussions, hands-on instruction, or multiple speakers are present).ConclusionsOur findings indicate that clinicians value dual-handset interpretation in bridging communication barriers and highlight recommendations to guide future implementation interventions to increase the uptake of remote language services in hospital settings.

IntroductionChinese Americans with limited English proficiency have higher mental health needs than English speakers but are more likely to be undiagnosed and undertreated for depression. Increasing anti-Asian hate crimes during the COVID-19 pandemic has increased the urgency to accurately detect depressive symptoms in this community. This systematic review examines the validity of the Patient Health Questionnaire (PHQ)-2/9 for depression screening in Chinese-speaking populations.MethodsWe queried PubMed, Web of Science, Embase, and PsycINFO databases, examining studies through September 2021. Studies were included if they evaluated the Chinese language PHQ-2 or PHQ-9 and diagnosed depression using a clinical interview. Two investigators independently extracted study data and assessed quality using the QUADAS-2. Study sensitivities and specificities were combined in random effects meta-analyses.ResultsOf 513 articles, 20 met inclusion criteria. All examined the PHQ-9; seven also examined the PHQ-2. Studies were conducted in Mainland China (17), Hong Kong (1), Taiwan (1), and the United States (1). Fourteen studies were published in English; six in Chinese. Studies were diverse in setting, participant age, and comorbidities. For the Chinese language PHQ-9, Cronbach's alpha ranged from 0.765 to 0.938 for included studies (optimal cutoff scores ranged from 6 to 11). For the PHQ-2, Cronbach's alpha ranged from 0.727 to 0.785 (optimal cutoff scores 1-3). Overall, the PHQ-9 pooled sensitivity was 0.88 (95% CI 0.86-0.90), and pooled specificity was 0.87 (95% CI 0.83-0.91). Similarly, the pooled PHQ-2 sensitivity was 0.84 (95% CI 0.80-0.87), and pooled specificity was 0.87 (95% CI 0.78-0.93). The overall risk of bias was low (12 studies) or indeterminate (8 studies).DiscussionWhile limited by missing study information, the Chinese language PHQ-9 appears to be a valid depression screening tool among Chinese-speaking populations across geographic and clinical settings. Further research should explore optimal cutoff scores for this population for routine depression screening and the validity of the tool to measure response to depression treatment.

ObjectiveThis study aimed to determine the prevalence and correlates of unmet need for mental health counseling among U.S. adults during the COVID-19 pandemic.MethodsData from the December 9-21, 2020, cross-sectional Household Pulse Survey (N=69,944) were analyzed.ResultsOverall, 12.8% of adults reported an unmet need for mental health counseling in the past month, including 25.2% of adults with a positive screen for depression or anxiety. Among adults with a positive screen, risk factors associated with an unmet need for mental health counseling included female sex, younger age, income below the federal poverty line, higher education, and household job loss during the pandemic, while protective factors included Asian and Black race.ConclusionsOver one-quarter of U.S. adults with a positive screen for depression or anxiety experienced an unmet need for mental health counseling during the pandemic. Policy makers should consider increasing funding for mental health services as part of pandemic relief legislation.

To assess whether primary care medical homes (PCMHs) are accurately identified for patients receiving care in a specialty mental health clinic within an integrated public delivery system. This study reviewed the electronic records of patients in a large urban mental health clinic. The study defined 'matching PCMH' if the same primary care clinic was listed in both the mental health and medical electronic records. This study designated all others as 'PCMH unknown.' This study assessed whether demographic factors predicted PCMH status using chi-square tests. Among 229 patients (66% male; mean age 49; 36% White, 30% Black, and 17% Asian), 72% had a matching PCMH. Sex, age, race, psychiatric diagnosis, and psychotropic medication use were not associated with matching PCMH. To improve care coordination and health outcomes for people with severe mental illness, greater efforts are needed to ensure the accurate designation of PCMHs in all mental health patient electronic records.

Purpose: Asian and Latinx individuals have a high burden of untreated depression. Under-recognition of depressive symptoms may contribute to existing disparities in depression treatment. The objective of this cross-sectional study was to determine whether physicians recognize and treat depressive symptoms for Chinese and Latinx patients during routine primary care visits. Methods: We analyzed data from 1171 Chinese and Latinx patients who were interviewed within 1 week after a primary care visit in a large academic practice, which had not yet implemented universal depression screening. We included participants with depressive symptoms (defined as a Patient Health Questionaire-2 score ≥3) and no prior history of depression (N=118). We investigated whether patients perceived having a mental health need in the prior year and conducted chart reviews to assess provider recognition of depressive symptoms, defined as documentation of symptoms, antidepressant initiation, or mental health referral within 30 days of the visit. We further examined differences by race/ethnicity and language preference. Results: Among the 118 patients with depressive symptoms and no prior depression diagnosis (mean age 68), 71 (61%) reported a mental health need in the prior 12 months; however, providers recognized depressive symptoms in only 8/118 patients (7%). The number of patients with recognized symptoms was small across race/ethnicity and language preference groups and we found no significant differences. Conclusion: Physicians recognized and documented depressive symptoms for 1 in 10 Chinese and Latinx patients during routine primary care visits. Targeted efforts are needed to address under-recognition of symptoms and improve depression care for these populations.

BackgroundEthnic minorities who present with mental health symptoms in primary care are less likely to receive treatment than non-Hispanic whites; language barriers may magnify this disparity.ObjectiveWe examined the contributions of ethnicity, gender, and English proficiency to unmet mental health need.DesignCross-sectional study.ParticipantsChinese and Latino primary care patients with a preferred language of English, Cantonese, Mandarin, or Spanish.Main measuresParticipants were interviewed within 1 week of a primary care visit and asked whether in the prior year they (1) needed help with emotional or mental health symptoms and (2) had seen a primary care physician or a mental health professional for these symptoms. Among those who reported "mental health need," we defined "unmet mental health need" as no reported use of services for these symptoms. Regression models explored independent and interaction effects among ethnicity, gender, and English proficiency, on the two outcomes.Key resultsAmong 1149 participants (62% women; 262 Chinese, with English proficiency [EP], 532 Chinese, with limited English proficiency [LEP], 172 Latino with EP; and 183 Latino with LEP), 33% reported mental health need. Among Chinese, but not Latino, participants, those with LEP were more likely than those with EP to report mental health need (AOR 2.55, 95% CI 1.73-3.76). Women were more likely to report mental health need than men (AOR 1.35, 1.03-1.79) regardless of ethnicity or English proficiency. Among participants reporting mental health need, 41% had unmet mental health need. Men with LEP, compared with those with EP, were more likely to have unmet mental health need regardless of ethnicity (AOR 2.53, 1.06-6.04).ConclusionsWe found high levels of mental health symptoms and unmet mental health need in both Chinese and Latino primary care patients. These results affirm the need to implement depression screening and targeted treatment interventions for patient subgroups at highest risk of untreated symptoms, such as men with LEP.

Purpose: The population with limited English proficiency (LEP) in California is growing. We sought to determine whether enough primary care physicians (PCPs) have the language skills to meet patient needs. Methods: The authors determined the number of PCPs who self-report proficiency in the five most common non-English languages spoken in California (Spanish, Cantonese, Mandarin, Tagalog, and Vietnamese) using Medical Board of California data from 2013 to 2015. The authors estimated LEP populations during 2011-2015 using Census data. They calculated PCP supply (the ratio of PCPs/100,000 LEP individuals) compared to a federal standard to judge adequacy. They performed a sensitivity analysis adjusting the percentage of LEP patients in a bilingual physicians' practice from 100% to the percentage of LEP individuals in California who spoke that language. Results: Of 19,310 PCPs in California, 15,933 (83%) provided information about languages they speak. There were 5,203 (33%) Spanish-, 486 (3%) Cantonese-, 986 (6%) Mandarin-, 956 (6%) Tagalog-, and 671 (4%) Vietnamese-speaking PCPs. PCP supply, compared to a federal standard, was adequate if we assumed that bilingual PCPs only care for LEP patients. However, if one assumes the number of LEP patients in a PCP's practice reflects the percentage in the general population, there is a large PCP undersupply for all languages. Conclusion: Estimates of access to language-concordant PCPs for LEP individuals are sensitive to assumptions about the percentage of LEP patients in a PCP's panel. Ensuring language-concordant access will require deliberate effort to match LEP patients with bilingual PCPs.

BACKGROUND:A large and increasing proportion of health care costs are spent caring for a small segment of medically and socially complex patients. To date, it has been difficult to identify which patients are best served by intensive care management. OBJECTIVE:To characterize factors that best identify which complex patients are most suited for intensive care management. DESIGN:We conducted a mixed-methods study involving 35 care managers (CMs; 10 licensed social workers and 25 registered nurses) working in intensive care management programs within Kaiser Permanente Northern California (KPNC) outpatient medical centers. We asked CMs to review a randomly selected list of up to 50 patients referred to them in the prior year and to categorize each patient as either (1) "good candidates" for care management, (2) "not needing" intensive care management, or (3) "needing more" than traditional care management could provide. We then conducted semi-structured interviews to understand how CMs separated patients into these three groups. RESULTS:CMs assigned 1178 patients into the 3 referral categories. Less than two thirds (62%, n = 736) of referred patients were considered good candidates, with 18% (n = 216) categorized as not needing care management and 19% (n = 226) as needing more. Compared to the other two categories, good candidates were older (76.2 years vs. 73.2 for not needing and 69.8 for needing more, p

BACKGROUND:Patients with limited English proficiency (LEP) have high rates of depression, yet face challenges accessing effective care in outpatient settings. We undertook a systematic review to investigate the effectiveness of the collaborative care model for depression for LEP patients in primary care. METHODS:We queried online PubMed, PsycINFO, CINAHL and EMBASE databases (January 1, 2000, to June 10, 2017) for quantitative studies comparing collaborative care to usual care to treat depression in adults with LEP in primary care. We evaluated the impact of collaborative care on depressive symptoms or on depression treatment. Two reviewers independently extracted key data from the studies and assessed risk of bias using the Cochrane bias and quality assessment tool (RCTs) and the Newcastle-Ottawa Quality Assessment Scale (non-RCTs). RESULTS:Of 86 titles identified, 15 were included (representing 9 studies: 5 RCTs, 3 cohort studies, and 1 case-control study). Studies included 4859 participants; 2679 (55%) reported LEP. The majority spoke Spanish (93%). The wide variability in study design and outcome definitions precluded performing a meta-analysis. Follow-up ranged from 3 months to 2 years. Three of four high-quality RCTs reported that 13-25% more patients had improved depressive symptoms when treated with culturally tailored collaborative care compared to usual care; the last had high treatment in the control arm and found equal improvement. Two non-RCT studies suggest that Spanish-speaking patients may benefit as much as, if not more than, English-speaking patients treated with collaborative care. The remaining studies reported increased receipt of preferred depression treatment (therapy vs. antidepressants) in the intervention groups. Eight of nine studies used bilingual providers to deliver the intervention. DISCUSSION:While limited by the number and variability of studies, the available research suggests that collaborative care for depression delivered by bilingual providers may be more effective than usual care among patients with LEP. Implementation studies of collaborative care, particularly among Asian and non-Spanish-speakers, are needed.

ObjectiveAlthough primary care is associated with better outcomes, many individuals with serious mental illness do not receive general medical services. This study examined patient-level factors associated with not having outpatient general medical visits among individuals with serious mental illness in California.MethodsThe study analyzed administrative, pharmacy, and billing data for 56,895 Medicaid-enrolled adults with serious mental illness treated in community mental health clinics between October 1, 2010, and September 20, 2011. Poisson regression estimated independent associations between predictor variables and outpatient general medical visits.ResultsOne-third of participants (34%) had no outpatient general medical visits during the study. In multivariate analyses, younger adults (ages 18-27) were less likely than older groups to have such a visit (adjusted relative risk [ARR]=1.07 and 1.19, respectively, for ages 28-47 and 48-67). Women were more likely than men to have such a visit (ARR=1.29). Compared with whites, blacks were less likely to have an outpatient general medical visit (ARR=.93). Rural dwellers were less likely than urban dwellers to have such a visit (ARR=.64). Persons with drug or alcohol use disorders were less likely than those without such disorders to have an outpatient general medical visit (ARR=.95), and those with schizophrenia were less likely than those with any other psychiatric disorder examined to have such a visit.ConclusionsIndividuals with serious mental illness had low use of outpatient general medical services. Integrated care models are needed to engage these individuals and eliminate disparities in morbidity and mortality.

PurposeLow educational attainment has been associated with depression among Latinos. However, few studies have collected intergenerational data to assess mental health effects of educational mobility across generations.MethodsUsing data from the Niños Lifestyle and Diabetes Study, we assessed the influence of intergenerational education on depressive symptoms among 603 Mexican-origin individuals. Intergenerational educational mobility was classified: stable-low (low parent and/or low offspring education), upwardly mobile (low parent and/or high offspring education), stable-high (high parent and/or high offspring education), or downwardly mobile (high parent and/or low offspring education). High depressive symptoms were defined as scoring ≥10 on the Center for Epidemiological Studies Depression Scale-10 (CESD-10). We examined prevalence ratios (PRs) for depressive symptoms with levels of educational mobility. We used general estimating equations with log-binomial models to account for within-family clustering, adjusting for age, gender, and offspring and parent nativity.ResultsCompared with stable-low participants, the lowest prevalence of CESD-10 score ≥10 occurred in upwardly mobile (PR = 0.55; 95% confidence interval [CI] = 0.39-0.78) and stable-high (PR = 0.62; 95% CI = 0.44-0.87) participants. Downwardly mobile participants were also less likely to have a CESD-10 score ≥10 compared with stable-low participants (PR = 0.65; 95% CI = 0.38-1.11), although the estimate was not statistically significant.ConclusionsSustained stress from low intergenerational education may adversely affect depression. Latinos with stable-low or downwardly mobile intergenerational educational attainment may need closer monitoring for depressive symptoms.

ObjectivesTo determine whether diabetes mellitus increases depressive symptoms in older Latinos in a population-based cohort.DesignProspective cohort study.ParticipantsIndividuals from the Sacramento Latino Study on Aging aged 60 and older in 1998-99 and followed annually until 2008 (N = 1,586).MeasurementsDiabetes mellitus was defined according to self-report, fasting blood glucose of 126 mg/dL or greater, glycosylated hemoglobin of 6.5% or greater, or diabetic medication use. Depressive symptoms were defined as Center for Epidemiologic Studies Depression Scale (CES-D) score of 16 or greater or use of antidepressant medication. Multistate Markov modeling was used to assess the effects of time-dependent diabetes mellitus on transitions between three states over time: low CES-D score (normal), high CES-D score or treated (depressed), and death. Bivariate analyses identified covariates significantly associated with any transition, including sex and baseline measures of age, education, body mass index, hypertension, and stroke.ResultsIn a fully adjusted model, participants with diabetes mellitus had a 35% higher rate of developing depressive symptoms or starting treatment with an antidepressant (hazard ratio (HR) = 1.35, 95% confidence interval (CI) = 1.13-1.62). Time-dependent diabetes mellitus was associated with a lower rate of regression from depressed to normal (HR = 0.72, 95% CI = 0.59-0.88) and a 2.3 greater rate pf progression from depressed to death (HR = 2.31, 95% CI = 1.57-3.40).ConclusionDiabetes mellitus increased the risk of developing depressive symptoms in older Mexican Americans. Older Latinos with diabetes mellitus should be screened for depressive symptoms and prioritized for close follow-up, potentially through greater reliance on team-based models of care.

Background: The COVID-19 pandemic has greatly increased telehealth usage in the United States. Patients with limited English proficiency (LEP) face barriers to health care, which may be mitigated when providers work with professional interpreters. However, telehealth may exacerbate disparities if clinicians are not trained to work with interpreters in that setting. Although medical students are now involved in telehealth on an unprecedented scale, no educational innovations have been published that focus on digital care across language barriers. Objective: The aim of this study is to investigate advanced medical students' confidence in caring for patients with LEP during telehealth encounters. Methods: We administered a written survey to medical students on clinical clerkships at one US institution in August and September 2020. We assessed students' overall confidence in working with interpreters; confidence in performing 8 clinical tasks during in-person versus telehealth encounters; and frequency of performing 5 different clinical tasks with patients with LEP compared to English-speaking patients during in-person versus telehealth encounters. Wilcoxon signed-rank tests and chi-square tests were used to compare confidence and task performance frequency, respectively, for patients with LEP versus English-speaking patients during telehealth encounters. Students were also asked to identify barriers to care for patients with LEP. The free-response questions were qualitatively analyzed using open coding to identify key themes. Results: Of 300 medical students surveyed, 121 responded. Furthermore, 72 students answered >50% of questions and were included in the analyses. Compared to caring for patients with LEP during in-person encounters, respondents were less confident in working with interpreters (P<.001), developing trust (P<.001), identifying agenda (P=.005), eliciting preferences for diabetes management (P=.01), and empowering patients in lifestyle modifications (P=.04) during telehealth encounters. During both in-person and telehealth encounters, approximately half of students (40%-78%) reported engaging less frequently in every clinical task with patients with LEP and this was as low as 22% (13/59) for some tasks. Students identified these key barriers to care for patients with LEP: time pressure, interpretation quality and access, technical difficulties, cultural differences, and difficulty with rapport building. Conclusions: Advanced medical students were significantly less confident caring for patients with LEP via telehealth than in person. Broader implementation of training around navigating language barriers is necessary for telehealth care, which has rapidly expanded in the United States. Our study identified potential key areas for curricular focus, including creating patient-centered agendas and management plans within the constraints of virtual settings. These developments must take place simultaneously with systems-level improvements in interpreter infrastructure to ensure high-quality care for linguistically diverse patients. [ABSTRACT FROM AUTHOR]

I. INTRODUCTION U.S. society is changing. Just turn on the television and see. Each week, millions of devoted fans tune in to shows like 'Modern Family' and 'The New Normal,' [...]

Background: Ethnic minorities who present with mental health symptoms in primary care are less likely to receive treatment than non-Hispanic whites; language barriers may magnify this disparity.Objective: We examined the contributions of ethnicity, gender, and English proficiency to unmet mental health need.Design: Cross-sectional study.Participants: Chinese and Latino primary care patients with a preferred language of English, Cantonese, Mandarin, or Spanish.Main Measures: Participants were interviewed within 1 week of a primary care visit and asked whether in the prior year they (1) needed help with emotional or mental health symptoms and (2) had seen a primary care physician or a mental health professional for these symptoms. Among those who reported "mental health need," we defined "unmet mental health need" as no reported use of services for these symptoms. Regression models explored independent and interaction effects among ethnicity, gender, and English proficiency, on the two outcomes.Key Results: Among 1149 participants (62% women; 262 Chinese, with English proficiency [EP], 532 Chinese, with limited English proficiency [LEP], 172 Latino with EP; and 183 Latino with LEP), 33% reported mental health need. Among Chinese, but not Latino, participants, those with LEP were more likely than those with EP to report mental health need (AOR 2.55, 95% CI 1.73-3.76). Women were more likely to report mental health need than men (AOR 1.35, 1.03-1.79) regardless of ethnicity or English proficiency. Among participants reporting mental health need, 41% had unmet mental health need. Men with LEP, compared with those with EP, were more likely to have unmet mental health need regardless of ethnicity (AOR 2.53, 1.06-6.04).Conclusions: We found high levels of mental health symptoms and unmet mental health need in both Chinese and Latino primary care patients. These results affirm the need to implement depression screening and targeted treatment interventions for patient subgroups at highest risk of untreated symptoms, such as men with LEP. [ABSTRACT FROM AUTHOR]