Major Depressive Disorder Podcast

Race, Equity in Care, and Cultural Competence in Major Depressive Disorder

Madhukar H. Trivedi, MD; Lorenzo Norris, MD


March 07, 2023

This transcript has been edited for clarity. For more episodes, download the Medscape app or subscribe to the podcast on Apple Podcasts, Spotify, or your preferred podcast provider.

Madhukar H. Trivedi, MD: Hello. I am Dr Madhukar Trivedi from UT Southwestern in Dallas. Welcome to season two of Medscape's InDiscussion series on major depressive disorder. Today I'm very excited to bring on a guest to discuss race, equity in care, and cultural competence in major depressive disorder. So first, let me introduce our guest, Dr Lorenzo Norris, who is an associate professor and an associate dean of student affairs and administration at the George Washington University School of Medicine. Welcome to InDiscussion.

Lorenzo Norris, MD: Dr Trivedi, thank you so very much.

Trivedi: I like to start my conversations in this series by asking each of our guests a couple of important things. If you had to identify the biggest challenges we, as a field but especially in psychiatry and depression, face in terms of this topic, what would they be?

Norris: The biggest challenge that we face is how, in my opinion, to incorporate culturally competent interviews into our daily clinical setting where we can engage our patients in a way in which we're not just getting the history or hearing the story that we want, but we're really hearing the patient's story in a very meaningful way. In my opinion, unless this is done in a very practical way, a part of your everyday practice in which you feel comfortable, it's just very challenging to take all of this in and attack, if you will, a social determinant of health, which not being able to do a culturally competent interview is, or at least take cultural competency into context. So above and beyond the departmental, institutional, or political levels, I think about the day-to-day practice and the relationships that we have with our patients and how we can enter into a partnership with them in which we are curious and humble, but also engaged in their life story.

Trivedi: In terms of clinical practice, maybe we can start at the patient level. What do you see as things that we, in practice, do that we may want to start considering making a change on so that we can put into practice what you're talking about?

Norris: I would start with really taking our notes or cues from the DSM-5 as well as everything in regard to what it means to do a cultural formulation interview. If you read through this documentation, I think they have a lot of great suggestions. I've had the pleasure of supervising residents, medical students, and junior faculty throughout my career; as well, I'm trained as a consult liaison psychiatrist. But the question to me is how can we actually approach the patient and determine what their definition of the problem is and, potentially, what are the causes of it? Now, you do this by being open, and the cultural formulation interview gives us a number of suggestions with which to do this. But probably the biggest thing when I'm working with residents and medical students is that you have to take that cultural formulation interview, but you have to transform it into something that makes sense for you. You have to turn it into something that makes sense with your own language, your own self, but you do it in a way in which there's a humble spirit of engagement. For me, I always tell everybody that there are things or diagnoses that we are considering, but those are just words. I really need to hear it from you, the patient, in terms of what you're experiencing, how it makes sense with your own life. I may not even use the term "culture" or "race" or "ethnicity" … I use "you" and where you are at. So I think the first thing is really understanding the patient's problem and what their perception of the causes are but also utilizing your own language to do so.

Trivedi: Fantastic. So if you look at population-level epidemiological data, we do recognize, for example, in the diagnosis of bipolar disorder and the use of lithium vs atypical antipsychotics, there appears to be some degree of a lack of understanding on the part of providers and clinicians. How does one translate that into individuals? So if a patient is in front of you in your office, what are the kinds of things I should be aware of as a practicing psychiatrist?

Norris: Well, the kind of things you should be aware of as a practicing psychiatrist, as it relates to the use of medications and antipsychotics, is that many of our patients, particularly regarding their cultural framework, can come in with many different meaningful ideas about how an antipsychotic works, what it does, what taking an antipsychotic means in their community, and whether or not this is an appropriate way for them to deal with stress or their illness. So I think it's really important to actually understand what it is that a patient brings from their own culture or identity into the mix. So, for instance, I'll use a little bit from my own background. I'm from Cleveland, Ohio, and I'm African American, and I can tell you from my own cultural upbringing in terms of what I grew up in, there was a stigma in regard to mental health. As a matter of fact, it was not even really discussed at all. Nobody spoke about mental health. If you had a family member that was hospitalized, you would never speak of it. These matters were not discussed. There was more of a heavier lean towards faith-based practices. So, when you would talk about something like depression or anxiety or things of that nature, depending on how the clinician or the person approached the patient or the member of the community, that could do it right then and there. As opposed to asking them what they have gone through or what they are experiencing. So, for instance, sometimes it's easier to start with, "What are you feeling in terms of the symptoms, the physical symptoms or things of that nature?" And then let's work our way into the mood and all of those other things. I'm giving you one example of many. I will keep coming back to the ideas of curiosity and engagement, but also noting that being aware of how — and again this gets to how to engage in your community — how is mental illness viewed in your community? And what are the preferred ways in which you can start to talk about this, to have somebody get the assistance or help that they need? So I think, again, going back to your question, particularly with antipsychotics, antidepressants, any type of medication, I think the biggest thing that you probably would want to do is not only stay curious and engaged, but people want collaborative partnership. If you come about it in an overly paternalistic fashion, if you're not partnering with your patient, if you're just [saying], "This is your diagnosis, this is what's there, this is the only thing that can work." Whether you say that directly or indirectly, that's a very big problem.

Trivedi: And I think it sounds like you're talking about really being much more cognizant of how best to do shared decision-making, right?

Norris: Absolutely.

Trivedi: Engaging the patient in the decision-making about their diagnosis but also about their treatment, about their prognosis, about the follow-up, etc. And in terms of shared decision-making, you raised a very important point. Maybe give us some concrete examples of how best to get out their personal biases one way or the other. And for example, you ideally, in shared decision-making, do bring out from patients whether they prefer medication or therapy, whereas this is a different aspect that is not always practiced. So, maybe give us some guidance.

Norris: All right. Here, to give you an example of what I would think in terms of a way to go about shared decision-making. Not only does it come from curiosity and engagement, but it comes from, in my opinion, working with a patient to identify not only what they find meaningful, but what are their strengths? How did you cope? How did you deal with this problem? How have you dealt with it in the past? I can almost guarantee you that anybody listening to this podcast right now, if they're working with a patient, the patient has coped and dealt with many things before they ever walked into our office, our emergency room, our televisit, or anything of that nature. If we acknowledge to the patient that not only do we know that you, the patient, have your own coping resources, your own style, that is informed by your own background, your own life experiences, which certainly gets into the cultural upbringing, then I believe that we are actually at a point of discussion. So this works. To give you an example, I cope through my spirituality. Or I cope through my physical exercises or I cope by really focusing on my work and taking a great deal of pride in X, Y, or Z. Once you identify those strengths, then you can start to plan around that person's strength. I personally find that when you enter into — and Dr Trivedi, I'm so glad you used that term, collaborative decision-making — once you enter into collaborative decision-making, I think that further allows us to engage in this cultural formulation because you start to hear, Okay, you [the patient] cope this way. When did you do that? Is this part of your identity? Is this part of your background? Is this what you find meaning in? And then it comes about naturally as opposed to somebody going, in somewhat of a formulaic way, down a checklist or interview. And Dr Trivedi, you actually mentioned this earlier — what is the biggest mistake that I think that clinicians can make? I think it is going down a checklist approach. I think whether you're doing a Structured Clinical Interview for the DSM (SCID), whether you're doing a PHQ-2 or a PHQ-9, for that matter, people do not respond to checklists. They respond to an authentic interaction in which you're trying to get to know them. And then I believe these things naturally come out. And that's your opportunity to go a little bit deeper in.

Trivedi: Wonderful. I think you bring out something that I would like us to talk a little more about, because it applies not only particularly to this topic of how best to be culturally appropriate in terms of race and ethnicity, but it is actually true for all our patients. What you are highlighting is how do we bring out their approaches to coping and strengths that they bring to this so that they become allies in our treatment rather than ignored?

Norris: Absolutely. So I think when we're talking about bringing out strengths and aligning with folks, I already talked about one, working with them to identify what is their strong point? But I also think that you want to work with them in terms of identifying what obstacles are currently interfering with them exercising those strengths. Which is different from a deficit model. So let's say, for instance, if we use a model, one of the ways in which I [the patient] actively cope is by actively problem solving. When my child was dealing with this, I researched and found this. When I was going through this at my job, I was able to align and figure this out. Okay, so that's something that works for you. What is working to prevent you from problem solving? Does your cultural background or perspective or race have any bearing in dealing with these challenges or difficulties? I may not say it like that, but I have a keen ear open for it. So I think that, again, not only do we identify strengths, but also it's important as a link in collaborative decision-making as well as shared creation of what is going on exactly in the patient's world. I think we need to help them identify what is not allowing them to act on the strengths. In this, I want to take a moment and go back to something else that you said in regard to that at the start. What are different things that clinicians can do or maybe things that they need to be aware of? We talk about curiosity. We talk about not going down a checklist. The other thing I think I would say is none of us are perfect. You're going to make mistakes. And I think you should be vulnerable. If I said something that you [the patient] took the wrong way or that you found inappropriate, I think the best thing that I can do is to own that. And one of the best examples that I saw during my CL training was with my attending up at Yale, Dr Paul Desan. The thing I always remember with Dr Desan is if he needed to stay in your [the patient's] room for 2 hours to make sure he got the story from you, he would do that. I wish I could still get that standard that Dr Desan did with every single patient, as far as I was concerned. That, to me, is very important that if you make a mistake, you own it. And I don't care how you sound, don't try to sound like the patient. Be yourself, and be humble, and acknowledge mistakes.

Trivedi: And in fact, it reminds me of one question I have, and that is as you correctly point out, we may not be ideal for every patient. So when you get to that, how do you approach it where you want to get help from somebody, some other expert who can help that particular patient? Do you raise it with the patient? How do you do it?

Norris: You know, Dr Trivedi, that's a great question. And this goes back to my original premise of culturally competent or culturally informed interviews, if you will, in terms of how we incorporate them into our practice. One, I believe that you start with every patient, and you say, "This is about you and it's about the proper fit. I may or may not be that proper fit for you." You can do this at any point in time, but I frequently do it when I first meet a patient. And periodically in different forms: "But even if I'm not the best fit for you, I want to partner with you to find us a clinician who is. With that being said, I definitely would like the opportunity to better understand what aspects of our fit are off and maybe have the opportunity to see if there's a way in which we can improve this relationship. Because I know of all the effort and work that you put forth just to get to this appointment. And if there's a way in which we can make this relationship work to your benefit, I would like to make that attempt to do so. But if not, that is also fine and we can transition. There are also times when it is appropriate, for many different reasons, to transition. But again, that idea that we are partners, but at the same time I need you to partner with me and educate me as to where I'm off. And I am okay admitting that, and saying that and being vulnerable, that I don't have the answers, that I do need to learn from you. That I could definitely be missing something."

Trivedi: Thank you so very much, Dr Norris. And I'd like to take the rest of our time to step away a little bit from individual patients to our practice, to our departments, and try to get an idea of how best to actually now incorporate this knowledge into a better working environment.

Norris: So how to best incorporate this into a better working environment? Now, obviously this depends on your department: different departments where you're at, whether you're at a university, a not-for-profit, or whether you are at another institute such as a for-profit or a Kaiser or what have you or your private practice. I'm going to think about it in terms of a couple of lenses, as to why you want to incorporate this. The first one is the moral imperative. We want to give our patients the best care possible. We want to do this. We believe that this will make a difference in our patients' care. The next thing that we look at is from a research lens. And we definitely know that if we are not actually thinking in a culturally sensitive or competent manner, this can lead to misdiagnosis. This can lead to racial biases. This can lead to microaggressions. It can lead to a great number of things. So we have an evidence base out there that supports the use of cultural formulations. And then the other thing I would say, because I am older now, is there is a business perspective. If you are delivering a form of care where people feel valued, meaningful, and it is high quality, that is going to really affect word of mouth and people coming to you. So why am I bringing this up? I think that if you're going to have a change, you're going to need to actually approach that change from at least three or four different motivating factors because everyone is motivated by different things or a combination thereof. Now, once you get that motivation to decide, You know what, we're going to do this, we are going to do this, then you get into the formal training, whether it is your in-services, your workshops, your grand rounds, whether it's your webinars, all of that. But I think the thing is first, developing the motivation, getting the input of others, and then saying, How are we going to do this on a practical level? So for instance, if Dr Trivedi and I just came together and said, "You know what, we think it's time. Cultural formulation interviews — who is with us?" I mean, as much as I'd like to think that Dr Trivedi and I are persuasive people, we may not get that much interest. Particularly when people are trying to meet their relative value units (RVUs), but initially thoughts, then imperative and mandate and buy-in, and then systematic training in a way that makes sense to how you incorporate it into your daily practice. And I'd say small steps. Don't try to do everything all at once. Small steps.

Trivedi: Thank you very much. That was a wonderful discussion. Before we end, Dr Norris, I'd love to get your final thoughts. Maybe some brief "dos and don'ts" that a practicing provider should be thinking about?

Norris: One, realize that a cultural formulation or understanding the patient's culture with respect not only adds meaning, not only does it add value or richness to your interview, it informs your diagnosis and can make it more evidence-based. So that's the first thing. Second thing is that you have to be very mindful in regard to going down a checklist approach. Don't ask questions just in a robotic fashion that does not play off of where the patient's leading you; that is not done in a collaborative decision-making manner. Third thing, just because you may share an overt aesthetic culture with the patient, do not assume that you understand the patient's cultural perspective. I will use myself as an example. I cannot assume because I'm African American that my cultural experience is similar to any African American that's coming in to talk with me. That's actually one of the biggest mistakes I think people make. I must still always be curious about that. Fourth, do this in small steps and add elements to your interview where it allows you to actually go into, for lack of a better word, fuller cultural formulations. But if you don't start with smaller questions or that spirit, then that is going to be an issue. And then probably, the last thing is as it relates to training, as it relates to many of the things that we're doing, whether it is in terms of changing how we work with our patients in a variety of settings, we have to start building these skills. It's going to take a little bit of time and work, but hopefully by the time the next generation of psychiatrists and mental health professionals are out, this will be second nature and they'll be doing this, along with their genetic sequencing, along with their AI-assisted diagnostic modalities, and all of this. And there'll be a time where we will just be like, Of course! Why weren't we doing this? So those are my thoughts.

Trivedi: Thank you very much. Thank you, Dr Norris, for a wonderful discussion. Today, we've talked to Dr Lorenzo Norris about how best to address the issues of race, equity in care, and cultural competence in major depressive disorder. Hopefully, our practices will become more enriched because of this. So thank you again, Dr Norris, and thank you all for tuning in. If you have not done so already, take a moment to download the Medscape app to listen and subscribe to this podcast series on major depressive disorder. This is Dr Madhukar Trivedi for InDiscussion. Thank you.

Listen to additional seasons of this podcast.



Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR)

The Cultural Formulation Interview: Building the Case for Cultural Competence in Clinical Care

Shared Decision Making

Promoting Collaborative Psychiatric Care Decision-Making in Community Mental Health Centers: Insights From a Patient-Centered Comparative Effectiveness Trial

Structured Clinical Interview for the DSM

Psychometric Properties of Structured Clinical Interview for DSM-5 Disorders-Clinician Version (SCID-5-CV)

The Patient Health Questionnaire-2: Validity of a Two-Item Depression Screener

The PHQ-9: Validity of a Brief Depression Severity Measure

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