The ways in which clinicians, such as NPs, communicate with patients could impact patients’ willingness to engage with mental health treatment.1 For this study, treatment engagement referred to how patients initiate, maintain, and participate in treatments such as pharmacotherapy and psychotherapy. A better understanding of the communication factors contributing to disparities in treatment engagement could help reduce those disparities and aid clinicians in using a more culturally appropriate approach to interacting with ethnic/minority populations.1
Why was the research needed?
Racial/ethnic minority populations with mental health needs have low treatment engagement rates compared with majority populations, including a 20% to 50% lower likelihood of initiating mental health treatment, a 40% to 60% lower likelihood of filling prescriptions, and a 40% to 80% increased likelihood of early treatment discontinuation.1 When patients with mental illness do not fully engage in treatment, they may experience symptom exacerbation and rehospitalization.2
Studies have shown that clinicians can improve their communication styles with patients of racial/ethnic minority status. As it stands now, they may involve these patients less in treatment decision making, struggle to build rapport, and fail to ask patients about their cultural views and treatment preferences.1 A comprehensive assessment of these issues could help clarify the specific ways in which clinicians’ communication styles affect patient engagement and thus potentially inform needed changes.
What did the researchers do?
The authors performed a systematic literature review that included searching 5 databases (i.e., PubMed, PsychInfo, Embase, CINAHL, and the Cochrane Library) for published literature from inception through November 2014. Secondly, they searched cultural mental health and social science journals by hand, as well as reviewed grey literature databases indexing health publications .1
Articles were screened and analyzed to examine the content of patient-clinician interactions (e.g., the patient’s cultural interpretation of the illness and treatment) and the context of those interactions (e.g., the clinician’s behavior toward the patient). Information about treatment engagement was coded in a database and categorized according to whether it referred to treatment initiation, treatment participation, or treatment continuation.1
The authors developed a framework to assess the quality of communication reported in each study, in 4 key areas, as shown in the table below.1
Framework for the Quality Assessment of Articles Reviewed
|Reporting||External Validity ||Internal Validity ||Study Design |
|The degree to which the study clearly reported its aims, sample, outcomes, and findings. ||Whether the sample they studied was representative of the entire population from which the sample was recruited. ||Whether the study used appropriate and reliable tests to measure cross-cultural communication and treatment engagement. ||The degree to which the study was able to report on causal relationships among the variables studied. |
What were the main results of the study?
The authors identified 23 studies that met their inclusion criteria. Of these, 12 were U.S. studies, 6 were Australian, 3 were from the United Kingdom, 1 was from Spain, and 1 was from multiple countries in Europe. Findings regarding the 3 categories of treatment engagement are described below.1
Treatment initiation results
Analysis of 15 studies with communication content affecting treatment initiation revealed the most common reason for delayed initiation was patient beliefs that the mental health system/treatments could not help them. Other studies suggested that some patients also delayed initiating treatment because they attributed their mental illness to somatic causes. Stigma was the third reason found for delaying treatment.
Regarding contexts of communication that affected treatment initiation, 2 studies among Black women and Asian American individuals found patients delayed treatment initiation when they had concerns that the clinician was of a different ethnicity and would not understand their cultural needs or perspectives.
Treatment participation results
Analysis of 18 studies with communication content affecting treatment participation revealed patients commonly felt uncomfortable talking about their emotions during treatment when they viewed their clinician as a stranger.
Some patients (e.g., Bangladeshi women in the United Kingdom) had decreased participation in treatment because they wished for clinicians to be more instructive, whereas others (e.g., Asian individuals born in the United States, as opposed to foreign-born Asian individuals) preferred less instruction and more exploratory discussion. Specifically, exploratory discussions were those in which clinicians were less directive and instructive and instead encouraged patients to explore their own perspectives and desires.
Regarding contexts of communication that affected treatment participation, patient-clinician communication was more patient centered and associated with a more positive affect in patients when the clinician and the patient were both Latino versus when both were White or when the patient-clinician dyad was mixed. Additionally, both Black and non-Black clinicians working with Black patients reported greater trust and empathy in psychotherapy when the clinician was willing to discuss race issues.
Treatment continuation results
Analysis of 13 studies with communication content affecting treatment continuation found the strongest factor influencing whether to continue or discontinue treatment was patients’ perception of the necessity of treatment—especially the necessity of medication. The second-strongest factor in treatment continuation was the clinician’s willingness to communicate about the mental health problem in a way that was consistent with the patient’s perception of the problem. For instance, clinicians framing the mental health problem as an existential issue rather than a biomedical illness was associated with improved treatment continuation in Asian patients in the United States.
Regarding contexts of communication that affected treatment continuation, fears about clinicians violating privacy issues were often reported. Specifically, some patients who were of the same race/ethnicity as the clinician (e.g., South Asian women in the United Kingdom) expressed fears that the clinician would violate confidentiality while in shared community settings, which made treatment continuation less likely. African and Caribbean immigrants in the United Kingdom reported feeling frustrated with not having continuity of care and having to re-explain their symptoms and history to a new clinician at every visit. Finally, for Asian American patients, using an exploratory rather than directive communication style increased treatment continuation.
Findings from this literature review are limited by the small number of studies reviewed and the fact that the studies reviewed differed in their study design and methodology, which could make it hard to generalize these findings to the entire population of individuals with mental disorders.
Why are these results potentially important?
This review confirms that clinician communication barriers exist, that they can impact mental health treatment engagement among racial/ethnic minority patients, and that they require intervention.1 The results of this review could inform strategies to improve patient treatment engagement, especially strategies centered on addressing physician communication with racial/ethnic minority patients and the interpretation of their illness and treatment needs rather than strategies addressing patients’ health literacy.1 These findings are also important because they are consistent with culturally appropriate communication strategies supported by cultural interview scales, such as the DSM-5 Cultural Formulation interview, which lends further support for those tools.1
Going forward, mental health treatment engagement interventions for racial/ethnic minority populations need to be developed and tested, incorporating clinicians’ communication styles and patients’ illness interpretations and treatment preferences.1
Additional research is also needed to examine how social determinants of health, which are drivers of healthcare disparities among underserved populations, might impact and be impacted by patient-clinician communications. Finally, examining potential differences in communication and communication needs among underserved patients of different genders could also help better clarify differences in mental health treatment engagement among men and women.3-5
This summary was prepared independently of the study’s authors. The content presented here is provided for educational purposes only. It is not intended as, nor is it a substitute for medical care or advice. Healthcare professionals should use their clinical judgment when reviewing educational resources on NP Psych Navigator.
Aggarwal NK, et al. Patient Educ Couns. 2016;99(2):198-209.
Dixon L, et al. World Psych. 2016;15:13-20.
Krasnova A, et al. Drug Alc Dep. 2021226:108828.
Pedrelli P, et al. J Studies Alc Drugs. 2016;77(4):620-8.
Seidler ZE, et al. Am J Men’s Health. 2018;12(6):1882-900.