Addressing Social Isolation in Seniors of Color through Enhanced Depression Screening and
Treatment in Primary Care Settings
The Institute for Urban Family Health, Virna Little
Josephine Allen, Department of Policy Analysis and Management
Partners in a Joint Research Proposal to the
Cornell Institute for Translational Research on Aging
Joint Research Funding Request
Aging Priority Area
The proposed project seeks to promote the social integration of seniors of color through
development of culturally sensitive depression identification and treatment in primary care
settings. By improving the detection and treatment of depression, one of the most significant health
problems experienced by African American and Latino/a seniors in New York City, this project
will improve health outcomes and facilitate the promotion of social integration among these elders.
The project will promote training for the professional health care staff of the Institute for Urban
Family Health, a health care and social service agency, which provides care to thousands of New
York City seniors.
Specific Project Aims
The primary goal of this project is to close the gap between how patients of color view and present
depression and how primary care providers identify and treat depression in order to improve
depression care. This project will promote enhanced quality of life for seniors through improved
primary care interventions for those who present with depression. More specifically, we seek to
increase the number of health care patients of color over 60 years of age who are identified with
depression and effectively cared for by physicians and other health care providers working in an
underserved Bronx, New York community by providing depression specific cultural competence
training in community health centers who already screen patients over 60 for depression.
Our research hypothesis is that increased training in depression specific cultural competence will
decrease depression in seniors, as measured by the decrease in patient health questionnaire, or
PHQ-9 scores (a validated depression screening tool) in the centers where providers receive the
specialized training. In order to achieve the goal of maximizing the number of patients whose
depression is diagnosed and effectively treated, primary health care providers must receive training
and approach each primary care visit with the cultural sensitivity necessary to help overcome
existing barriers to detecting depression within this population. Anticipated results include
improved interactions and communication experiences that in turn will lead to fewer missed
primary and specialty care appointments, increased medication adherence and increased follow up
appointments with mental health professionals by African American and Latino/a seniors. The
improved care will result in decreases in depression symptoms and social isolation and improve
quality of life for these seniors.
Goals, Objectives and Outcomes
To achieve the goal of improving the detection and treatment of depression in seniors of color, we
will develop a curriculum focusing on culture bound depression symptoms and culture specific
approaches and treatments as an in-service training experience for health professionals and other
health care workers. The PHQ-9 was developed for use in a primary care setting, and relies on
patient self-report with follow-up verification by a clinician. This project is intended to
demonstrate that the tool is more effectively used in communities of color when clinicians are
trained in depression-specific cultural competency. Reductions in social isolation and improved
health and well-being are important expected outcomes.
Through this project, we will foster an active researcher-agency partnership in assessing and
promoting community treatment of depression, a leading mental health diagnosis among African
American and Latino/a seniors in New York City that is associated with diagnoses of hypertension,
diabetes, and cardio vascular disease. Associated benefits of this partnership include the
translation of the collaborative relationship, the research results, and the community benefits into a
larger proposal for external funding through NIA or through a foundation in order to replicate and
further validate this research.
Significance of the Project
The overall significance of this project is supported by the findings of the Macarthur Initiative on
Depression and Primary Care,1 which support the notion that improving primary care depression
treatment requires that patients with depression be diagnosed and their treatment monitored over
time. The PHQ-9 is self-administered, and with periodic re-administration this self-report measure
provides relatively objective information to determine whether changes in the treatment plan are
indicated. It was further determined that a valid and reliable self-report measure does not require
specific mental health clinical expertise to administer. The work of Spitzer, Kroenke and
Williams, among others,2 further supports this hypothesis.
The Macarthur Initiative on Depression and Primary Care at Dartmouth and Duke.
http:/www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/, accessed July 6,, 2006
See Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD in
PHQ Primary Care Study. Journal of the American Medical Association; 1999. 1737-1744; Kroenke K,
Spitzer RL, Williams JB. The PHQ-9 validity of a brief depression severity measure. Journal of General
Internal Medicine 2001; 16: 606-613;Rost, K., Smith, J. Retooling multiple levels to improve primary care
depression treatment. Journal of General Internal Medicine16: 644-645, 2001;Kroenke K, Spitzer RL.
The PHQ-9: A new depression and diagnostic severity measure. Psychiatric Annals 2002, 32: 509-521; and
Williams, JW, Noel, PH, Cordes, JA, Ramirez, G., Pignone, M. Is the patient clinically depressed? Journal
of the American Medical Association 2002; 287: 1160-1.
Research supports the importance of considering cultural patterns and practices as well as methods
of traditional healing when working with culturally diverse populations. Racial and ethnic
disparities in health status and in access to quality health care have been well-documented.3
In addition, the shortage of mental health services in the Bronx is a problem that has drawn
national attention. The few mental health services that are available to seniors are often in other
communities which are not easily accessible for older residents, require navigating large systems
such as a city hospital, or do not accept patients who are uninsured or underinsured. These barriers
prevent many seniors living in the Bronx from obtaining needed mental health services.
Additionally, most seniors, more than 50%, rely on their medical providers to treat mental health
problems, which is one reason why most seniors with mental health symptoms are never treated.
Research indicates that most seniors who commit suicide saw their primary care provider within
the month, many within the week. Given the data, it is imperative that primary care providers
working in underserved community health centers, such as the Institute’s Bronx practices, are able
to identify seniors with mental health concerns and treat them in an appropriate and culturally
competent manner. It is suspected that the current model of care suggested for the identification
and treatment of depression utilizing the PHQ-9 is not be as effective in underserved areas if the
providers are not adequately trained.4
The development and implementation of a culturally and historically sensitive curriculum for
primary health care professions that is designed to more effectively diagnose and treat depression
in African American and Latino/a seniors in primary care settings in several communities in New
York City should lead to improved mental health outcomes for these individuals and their
communities. Improvements in the health and mental health as well as in of the lives of these
seniors would be significant contributions.
Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in
Healthcare. Institute of Medicine of the National Academies. The National Academies Press.
Washington, DC. 2003. Arean, P., Ayalon, L., Hunkeler, E., Lin, E., Tang, L., Harpole, L., Hendrie, H.,
Williams, J., & Unutzer, J. (2005). Improving depression care for older, minority patients in primary
care. Medical Care, 43(4), 381-390.
Cooper, L., Gonzales, J., Gallo, J., Rost, K., Meredith, L., Rubenstein, L., Wang, N., & Ford, D.
(2003). The acceptability of treatment for depression among African-American, Hispanic, and White
primary care patients. Medical Care, 41 (4), 479-489;
Gallo, J., Bogner, H., Morales, K., & Ford, D. (2005). Patient ethnicity and the identification and active
management of depression in late life. Archive International Med., 165, 1962-1968.
Lubar, P.H., Meyers, B.S., Russo-Williams, P.G., Hollenberg, J.P., DiDomenico, T.N., Charlson, M.E., &
Alexopoulos, G.S. (2001). Depression and service utilization in elderly primary care patients. American
Journal of Geriatric Psychiatry, 9 (2), 169-176.
Miranda J., & Cooper, L. (2004). Disparities in care for depression among primary care patients. Journal
General Intern Med, 19, 120-126.
Skarupski, K., Mendes de Leon, C., Bienias, J., Barnes, L., Everson-Rose, S., Wilson, R., & Evans, D.
(2005). Black-White differences in depressive symptoms among older adults over time. The Journals of
Gerontology, 60(3), 136-142.
New York Academy of Medicine Roundtable, Washington, D.C., February, 2005.
Relevant Prior Experience
The Institute for Urban Family Health has been providing care and services to urban communities
for over twenty years, and is a leader in the provision of health care to underserved communities in
New York City. Over the past five years the Institute has implemented an electronic health
information system which provides improved patient care and allows for detailed reporting and
tracking of patient outcomes.
In the area of depression and primary care, the Institute has been a national leader as one of the
first primary care organizations to duplicate the Improving Mood Promoting Access to
Collaborative Treatment (Project IMPACT), a collaborative depression care management program,
in four of their community health centers. The Institute also participated in the New York City
Department of Health Chronic Illness Depression Collaborative and then continued the work as the
only member of seventeen into the spread initiative. Establishing an operational workflow and
building the PHQ-9 along with other depression specific care tools has further made the Institute a
leader in depression primary care work. At present the Institute is implementing further depression
tracking and identification tools in cooperation with the New York City Department of Health’s
“Healthy New York” initiative.
Virna Little, the Institute’s Vice President for Psychosocial Services, has developed curriculums
for primary care providers around depression care utilized during the collaborative projects. Ms.
Little has extensive training experience and has worked with other healthcare organizations around
the country to expand the knowledge of depression in primary care settings.
A pilot study, 2005-2006, supported by CITRA allowed us to develop aspects of the proposed
plan. A questionnaire for health care providers was developed and three focus groups were held
with African American and Latino/a seniors in order to assess their comfort with the PHQ-9 self-
assessment tool as well as to inquire about their assessment of the need for greater cultural
sensitivity as they sought to have their health care needs met. Three focus groups were conducted
to assess Black and Latino/a senior patients’ perceptions of the PHQ-9 and their and their health
care providers’ attitudes about addressing late life depression. The focus group participants were
Black and Latino/a patients, 60 years of age and over who are residing in the Bronx and receiving
primary health care from one of the five Institute for Urban Family Health’s Bronx health centers.
The focus group discussions were conducted in both English and Spanish. Focus group
participants felt comfortable in utilizing the diagnostic tool and saw it as necessary and applicable
across cultures. Elderly Black and Latino/a patients discussed the significance of the PHQ9
screening tool in detecting their depression because depression is not often talked about in their
cultures. Although the focus groups generated useful information, definitive statements about the
utilization of the PHQ-9 and health care providers’ cultural sensitivity were difficult to make
because of the small sample size. The proposed study builds on these findings and seeks to
strengthen the link between primary care providers’ cultural sensitivity and depression prevention
and treatment among African American and Latino/a seniors in New York City.
A curriculum will be developed by Ms. Little, LCSW-r, with the assistance of her colleagues and
input from Josephine Allen, Ph.D., of the College of Human Ecology. This curriculum will
emphasize both cultural sensitivity in primary care practice and the importance of using the PHQ-9
in diagnosing, monitoring and treating depression impairments in African American and Latino/a
seniors who are at least 60 years of age. A series of four in-service training sessions will be
developed and implemented in accordance with the stated project aims. In addition, the sessions
will include emphases on overcoming barriers to accessing mental health care and the comorbidity
of depression with diabetes, cardio-vascular disease, and hypertension. Two family practice
centers will serve as control sites for this project in order to determine the effectiveness of the
training in the other three centers.
In the proposed study calculations of the average site PHQ-9 scores will determine the
effectiveness of using the depression scale of the PHQ-9 by primary care physicians and other
health professionals. A total of 39 attending physicians, social workers, nurse practitioners, and
RN and LPN nurses at the Bronx practices participating in the research will be invited to in-service
training sessions. It is expected that there will be a high rate of participation because these training
sessions are strongly recommended by the administration of the Institute. After the study period,
15 corresponding personnel and 5 attending physicians at the Bronx practices that are our control
or comparison centers will be offered the training.
A monthly report will be generated through the electronic medical record system which will report
on the number of patients over 60 who have been identified with depression and each site’s
average PHQ-9 score for these patients. This information will be tracked monthly for both
participating (treatment) and control centers. Regular bi-weekly video or telephone conferences
will be held so that the research partners can monitor progress toward meeting the aims of this
The specific project aims will be achieved and the hypothesis will be tested in the following
manner: Three of the Bronx health centers will be treatment sites and two of the centers will be
control sites. The treatment sites will have health care providers who receive the four depression
specific cultural competence in-service training sessions during the first two months of the year-
long project. The control centers will participate in these training sessions during the ninth and
tenth months of the project. The total average score for the PHQ9 assessment for patients sixty
years and older in each of the five centers will be collected monthly. In addition, the number of
patients in this age cohort who are diagnosed with depression and those who are treated for
depression will be determined. Other measures will include reports of any changes in the overall
compliance with follow-up and specialty medical appointments; changes in rates of comorbidity of
depression with diabetes, hypertension and cardiovascular disease among the seniors participating
in this study. Demographic data for seniors participating in each of the centers will also be
collected, using the medical record system.
An assessment of the utility of the depression specific cultural competence training sessions will
be determined by monitoring the PHQ9 scores, the keeping of appointments, fidelity to medical or
therapy treatment protocols, and general health statuses.
Data will be entered and analyzed, using the SPSS statistical package.
Regression analyses, using baseline and post intervention data will be conducted. A multi-level
random coefficient model will be tested, using the center level intervention as a fixed effect and
patient level data within each center, controlling for such variables as age, gender, ethnicity/race,
and health status.
In addition, a regression analysis controlling for random centers will be explored.
T-tests, using the difference in PhQ9 scores in the treatment and in the control centers, will assess
the significance of these differences. Regression analyses of the monthly average PHQ9 scores
will also be completed.
A limitation of this analysis is that there is a small number (5) of centers included in the study,
however, within each center, there will be several hundred seniors who are sixty years of age and
who will be regularly screened, using the PHQ9.
This pilot study will allow us to determine the direction of the changes that are observed and to
justify a proposed larger study. The facts that Black and Latino/a seniors are our target population,
and that the five centers are demographically very similar, suggest that the study will provide very
important results and contribute to the literature on the use of the PHQ9 as useful diagnostic tool in
the detection and treatment of depression with this population.
Human Subjects Approvals
Prior to the October 1st start date, approvals from the University Committee on Human Subjects
and from the Institute for Urban Family Health’s IRB will be obtained if this proposal is funded.
Information on the Collaborating Agency and the Partnering Relationship
The Institute for Urban Family Health is a twenty-year-old non-profit organization dedicated to the
development of innovative ways to provide high quality, cost-effective primary heath care to
underserved urban populations based on the family practice model of care. The Institute also
sponsors innovative educational and training programs for health professionals. Most Institute
projects are developed and operated collaboratively with community-based organizations,
hospitals, universities and medical schools.
All Institute health centers are located in health professional shortage areas or serve predominantly
low income and special needs populations, including the uninsured. The Institute operates several
clinical programs serving special populations, including a Care for the Homeless program, four
Ryan White HIV/AIDS programs, two free clinics, a geriatric mental health program, and a
number of health professional training programs. In addition, the Institute participates in
numerous programs that support the goals of eliminating health disparities and providing access to
quality health care to all regardless of their ability to pay.
Four years ago, the Institute implemented Epic, a fully integrated electronic health record (EHR) at
its ambulatory care practices. This has greatly enhanced the organization’s capacity to deliver the
highest quality patient care through tracking systems, clinical decision supports, and printed health
summaries provided to patients at each visit, and permitted the Institute to partner with the New
York City Department of Health and Mental Hygiene in a number of public health activities.
Currently, the Institute offers care at twelve full-time and nine part-time primary care health
centers in the Bronx and Manhattan. The five Bronx full-time centers that will offer services in
conjunction with this project are all part of the Federal Community Health Center Program. They
include Urban Horizons Family Health Center, Walton Family Health Center, Mt. Hope Family
Practice, Park Chester Family Practice and Westchester Avenue Health Center.
The proposed project will focus on the neighborhoods served by the Institute’s Bronx practices,
including West Tremont, University Heights, Mount Hope, and Morrissania. The patient
population is predominantly low-income, African American and Latino. Roughly 75% of the
patients seen receive Medicaid, and 14% are uninsured. Educational levels are low, and
unemployment is high. Unfortunately, income is not evenly distributed among the elderly and
New York City’s elderly poverty rate is double that of the national average, almost 20% versus
10% nationally. Latino and African-American elderly make up 60% of the city’s elderly living
below or at poverty level. The most disadvantaged are two-thirds of Latino elderly who have
incomes below $10,000. One out of four impoverished seniors live on about $3 a day after paying
for food and housing. Most seniors served in the Institute’s Bronx practices are living in
overcrowded housing and experiencing many of these psychosocial stressors that impact their
medical and mental health.
The Institute has a long history of collaborating with both community and research partners. In
order to accurately track and analyze data surrounding patients identified in the centers with
depression and defined health outcomes project staff will provide health information of patient
participants in order to analyze data and program impact on health outcomes. Key research staff
will be provided with electronic medical record account numbers with limited clearance in order to
obtain data. These researchers will have signed confidentiality agreements along with both entities
The study findings will be shared with the professional community through the development of a
manuscript for publication in a peer-reviewed journal and the development of papers for
presentation at health professional conferences (such as the National Society for Social Work
Leaders in Health Care, the Community Health Care Association of New York State, the National
Council on Aging, the Association for Gerontology in Higher Education, and the Society for
Social Work Research,) and will thereby contribute to the general knowledge base about
depression and elderly people. The curriculum for primary care providers will be presented to
providers at the remaining Institute practices and will be made available to other community health
centers and primary care sites serving elderly people of color in the New York area. We anticipate
that our expected findings of improved depression care for minority seniors through the use of this
curriculum will be drawn upon by the broader primary care and mental health community to
Research Time Table
Ongoing Monthly Activities
Collection of data assessing the average PhQ9 scores of patient participants
Data Entry and Analysis
Regular consultation of the project partners
Applications will be submitted to the University Committee on Human Subjects and to
the Institute for Urban Family Health Internal Review Board.
Refinement and implementation of Professional In-Service I and Professional In-
Service II of the project’s educational curriculum for primary health care
Implementation of the Professional In-Service III and Professional In-Service IV
Implementation of Professional In-Service I and Professional In-Service II for the
Implementation of Professional In-Service III and Professional In-Service IV for the
Writing of the research report and scholarly articles
Presentation of findings to the Research Associates
Development of the NIA proposal for an extended and expanded project
Plan for Extending Project Funding -
A proposal will be prepared and submitted to the National Institute on Aging after the key
elements of the study are refined and data confirm a) the significance of including
education/training for health care professionals around cultural sensitivity and health practices as
well as barriers to primary health care among underserved populations; and b) the importance of
using the PHQ-9 among Populations of Color in underserved and economically disadvantaged
communities in order to diagnose, effectively monitor and treat depression in patients who are 60
years of age and older.
During April 2007, we will use the six months study results to begin recruiting additional
collaborators who work with racially diverse rural populations, while designing and incorporating
a longitudinal study that continues and expands the number of respondents included in the New
York City pilot study.
During August 2007 we will begin constructing the NIA application for funding for a comparable
study that includes more New York City respondents in addition to similar populations in several
in rural Upstate New York communities.
By January 2008 the proposal to NIA will be ready for submission.