Depression is one of the costliest and most prevalent health conditions in the U.S. with 21 million adults having experienced at least one major depressive episode. Despite the availability of evidence-based treatments for depression, a large proportion of people with new diagnoses fail to initiate formal mental health treatment. Although individuals across all racial and ethnic groups fail to initiate treatment for depression, historically minoritized racial/ethnic groups are at even greater risk. Thirty-four participants representing historically underserved racial and ethnic populations from two large health care systems in the U.S. participated in qualitative interviews or focus group to identify factors that impede and facilitate depression treatment initiation in primary care settings. Participants identified individual and systemic barriers and facilitators of treatment initiation for depression and suggested several ideas for increasing treatment engagement (i.e., increased communication and education from providers, community events, information on social media). Novel interventions are needed to improve treatment initiation following initial diagnosis of depression in primary care settings. Findings from this study offer suggestions for improving treatment initiation in traditionally underserved communities. •Depression treatment initiation is inhibited by patient and systemic level barriers.•Historically minoritized groups recommend community-based efforts.•A strong patient-primary care provider alliance can facilitate treatment initiation.