Blog Post

Confronting Implicit Bias to Adapt Depression Screening and Treatment

July 19, 2022

By Vaishnavi Vaidya, MPH, Program Manager, Healthforce Center at UCSF

Over the past 20 years, Tennessee has seen immense growth in the Latinx population due to a steady influx of migrant agriculture workers. To meet the health care needs of families in this community, Cherokee Health Systems (CHS), an integrated Federally Qualified Health Center (FQHC) opened a pediatric clinic along with prenatal care. Recently Dr. Parinda Khatri, Chief Clinical Officer of CHS, detailed how the health center had to rethink their existing protocols to improve the identification and treatment of depression in Latinx peri- and post-partum patients. CHS’s story provides a snapshot of how providers can have lapses in their practice but through reflection and education, improve workflows to better serve their communities and advance health equity.

Dr. Khatri shared the lessons learned with the California Improvement Network (CIN), a learning and action network that is funded by the California Health Care Foundation and managed by Healthforce Center at UCSF. (To learn about more great ideas for health care improvement, sign up for Healthforce Center’s newsletter and CIN’s newsletter.)

At CHS, providers noted that many of the patients coming into their clinic experienced many stressors such as poverty, immigration trauma, fears of deportation, and discrimination. However, standard screening protocol for clinical depression found little or no signs of depression among the Latinx patients. And contrary to the screening results, CHS staff reported that patients would frequently express feelings of withdrawal, low self-worth, learned helplessness, and self-criticism, along with immense fatigue and lack of sufficient sleep.

Data shows that generally about a quarter to half of all pregnant patients within the Latinx community experience peri- and post-natal clinical depression — a higher rate compared to non-Latinx white patients. Furthermore, studies show disparities in rates of mental health services utilization between Latinx patients (4 to 5%) and their non-Latinx white counterparts (10%).

CHS staff wanted to understand what was under the discrepancy they were seeing among the clinic’s patients, and how they could ensure that screenings provide more accurate assessments. CHS reevaluated their approach in the following ways:

  • Engaged in self-reflection and self-awareness. CHS providers and staff examined their own inherent biases that might impact how they interact with their patients. (A good resource is They identified certain structural characteristics of the care setting and interpersonal characteristics of their staff that could contribute to cultural mistrust among their patients.
  • Educated themselves. CHS looked to existing literature (see hereherehere, and here) on peri- and postpartum depression screenings within the Latinx community and found that much of existing research mirrored what they had seen at their facility: pregnant Latinx patients were more likely to report suppressing feelings of depression and anxiety out of fear of judgement from others, have misconceptions about what is depression, and less likely to seek out treatment for mental health.
  • Collaborated with patients and the community. CHS integrated community health workers into every step of prenatal care at the clinic to help build trust among their patients. For example, community health workers or promotores served as mentors to patients who were hesitant in seeking treatment for their depression or anxiety.
  • Adapted clinical practice. CHS took the critical learnings from speaking with their patients and external research to inform an adapted clinical process. Instead of just screening for depression, they implemented a system of screening plus supportive talk. Staff were trained to discuss typical experiences during pregnancy and help patients better label their emotions. CHS also learned to meet patients at their comfort level and allow for self-directed care instead of jumping straight to interventions.

Finally, CHS redesigned their workflow to implement a stepped pathway toward care:

  1. Use of existing resources: Encouraging connections with friends and family
  2. Formal support systems: Fostering formal mentorships such as linking patients with promotores
  3. Behavioral intervention: Cognitive Behavioral Interpersonal Therapy
  4. Antidepressant use: Only after delivery and if necessary

The story of Cherokee Health System can serve as an example for similar community providers and inspire organizations to challenge their biases and take an introspective look at how they can adapt their own practices. Established protocols are not always a one-size-fits-all solution and in order to meet the needs of a specific community, organizations must be willing to assess and change policies, continually train staff, and commit to ongoing quality improvement processes.

Watch the webinar now to learn more. This webinar was hosted by the California Improvement Network (CIN), a community of health care organizations that identifies and distributes ideas for better care delivery. CIN will be recruiting August - September 16 for its next programmatic cycle; check the website for information and subscribe to CIN’s monthly newsletter to learn more.