How doctors' communication style and race concordance influence African-Caribbean patients when disclosing depression

"How's your mood": Recorded physician mental health conversations with Chinese and Latino patients in routine primary care visits

OBJECTIVE

Patient-physician communication patterns may influence discussions around depressive symptoms and contribute to engagement in depression care among racial/ethnic minority adults. We examined patient-physician communication about depressive symptoms during routine primary care visits with Chinese and Latino patients with and without language barriers.

METHODS

We examined 17 audio-recorded conversations between primary care physicians and Chinese (N = 7) and Latino (N = 10) patients who discussed mental health during their visit and reported depressive symptoms on a post-visit survey. Conversations (in English, Cantonese, Mandarin, Hoisan-wa, Spanish) were transcribed and translated by bilingual/bicultural research assistants and analyzed using inductive and deductive thematic and discourse analysis.

RESULTS

Patients initiated mental health discussion in eleven visits. Physicians demonstrated care in word choice and sometimes avoided openly mentioning depression; this could contribute to miscommunication around symptoms and treatment goals. Interpreters had difficulty finding single words to convey terms used by either patients or physicians.

CONCLUSION

Patients and doctors appeared willing to discuss mental health; however, variability in terminology presented challenges in mental health discussions in this culturally and linguistically diverse sample.

PRACTICE IMPLICATIONS

Further understanding patient preferred terminology about mental health symptoms and interpreter training in these terms could improve patient-physician communication about depressive symptoms and treatment preferences.

A Systematic Review of Inequalities in the Mental Health Experiences of Black African, Black Caribbean and Black-mixed UK Populations: Implications for Action

BACKGROUND

Measurable differences in the experience and treatment of mental health conditions have been found to exist between different racial categories of community groups. The objective of this research was to review the reported mental health of Black African-Caribbean communities in the UK, determinants of mental health, and interventions to enhance their experiences of mental health services.

METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was applied. To be included, papers must be published in a peer reviewed journal; report on adult populations (over 18) from any of Black African, Black Caribbean or Black mixed people in the UK; and assess (quantitative), or discuss (qualitative) mental health experiences, determinants of mental health, or interventions intended to enhance experiences of mental health services among the target population. The aims, inclusion criteria, data extraction, and data quality evaluation were specified in advance. Searches were conducted using EBSCO (PsychInfo; MEDLINE; CINAHL Plus; psychology and behavioural sciences collection). The search strategy included search terms relating to the aim. Risk of bias was assessed using a standard tool, records were organised using Endnote, and data were extracted and synthesised using Microsoft Excel.

RESULTS

Thirty-six studies were included, of which 26 were quantitative and six reported exclusively on Black participants. Black populations were less likely to access mental health support via traditional pathways due to stigma and mistrust of mental health services. Black Africans especially, sought alternative help from community leaders, which increased the likelihood of accessing treatment at the point of crisis or breakdown, which in turn increased risk of being detained under the Mental Health Act and via the criminal justice system.

DISCUSSION

Findings suggest a cycle of poor mental health, coercive treatment, stigma, and mistrust of services as experienced by Black communities. Evidence was limited by poorly defined ethnic categories, especially where Black populations were subsumed into one category. It is recommended that mental health services work collaboratively with cultural and faith communities in supporting Black people to cope with mental illness, navigate mental health pathways, and provide culturally appropriate advice. Protocol Registration Number PROSPERO CRD42021261510.

Primary Care Physician Recognition and Documentation of Depressive Symptoms Among Chinese and Latinx Patients During Routine Visits: A Cross-Sectional Study

Purpose: Asian and Latinx individuals have a high burden of untreated depression. Under-recognition of depressive symptoms may contribute to existing disparities in depression treatment. The objective of this cross-sectional study was to determine whether physicians recognize and treat depressive symptoms for Chinese and Latinx patients during routine primary care visits. Methods: We analyzed data from 1171 Chinese and Latinx patients who were interviewed within 1 week after a primary care visit in a large academic practice, which had not yet implemented universal depression screening. We included participants with depressive symptoms (defined as a Patient Health Questionaire-2 score ≥3) and no prior history of depression (N=118). We investigated whether patients perceived having a mental health need in the prior year and conducted chart reviews to assess provider recognition of depressive symptoms, defined as documentation of symptoms, antidepressant initiation, or mental health referral within 30 days of the visit. We further examined differences by race/ethnicity and language preference. Results: Among the 118 patients with depressive symptoms and no prior depression diagnosis (mean age 68), 71 (61%) reported a mental health need in the prior 12 months; however, providers recognized depressive symptoms in only 8/118 patients (7%). The number of patients with recognized symptoms was small across race/ethnicity and language preference groups and we found no significant differences. Conclusion: Physicians recognized and documented depressive symptoms for 1 in 10 Chinese and Latinx patients during routine primary care visits. Targeted efforts are needed to address under-recognition of symptoms and improve depression care for these populations.

Individuation and implicit racial bias in genetic counseling communication

OBJECTIVES

Genetic counselors (GCs) can frame information in either general terms (i.e., population risks) or individual terms (i.e., tailoring to specific client characteristics). We investigated whether informational framing might reflect GCs' implicit racial bias.

METHODS

We analyzed previously videotaped genetic counseling sessions with white and minority (Black and Latino) simulated clients (SCs) and modeled the relationship between sixty GCs' implicit racial bias, as measured by the Implicit Association Test (IAT), and informational framing (general or individual) as characterized by the Roter Interaction Analysis System.

RESULTS

Higher (more pro-white) IAT scores predicted less informational individuation for minority relative to white SCs. Similarly, higher IAT predicted fewer facilitation and activation statements to minority relative to white SCs. With higher IAT-scoring GCs, minority SCs disclosed less psychosocial and lifestyle information, and asked fewer medical questions (all p < 0.05).

CONCLUSION

GCs' racial implicit bias may be associated with less individualized communication style when counseling minority clients.

PRACTICE IMPLICATIONS

Future research should address whether increasing informational individuation can ameliorate negative consequences of implicit bias and help providers reframe perceptions of minority patients in individual rather than categorical terms.

"You Have to Be Part of the Process": A Qualitative Analysis of Older African American Men's Primary Care Communication and Participation

The objective of the current study was to understand older African American men's perceptions of and experiences with patient-provider communication during primary care medical visits. Fifteen African American men age 50 and older participated in individual semistructured interviews. Open-ended questions focused on their primary care therapeutic alliance, preferences for decision-making, self-efficacy, patient satisfaction, communication, and companion participation during primary care medical visits. Emergent themes included the perception of rushed and inattentive care related to low socioeconomic status, inadequate information exchange about medical testing and follow-up care, welcoming the help of highly engaged companions, and proactively preparing for medical visits. Participants' assertiveness, confidence, and persistence with health providers regarding agenda setting for their care were most prevalent and contradict extant literature portraying African American men as less engaged or informed patients. Older African American men, particularly those with low socioeconomic status, may benefit from additional support and advocacy to consistently receive patient centered care and communication.

Psychology across cultures: Challenges and opportunities

Large variations of inequalities in rates of mental health disorders and access to mental health care exist within and between countries. Globally, disparities range from countries where there is little provision to those where, despite the availability of evidence-based mental health care, service access and outcomes are mediated by social factors such as socio-economic status, race/ethnicity, and culture. This is salient because increasingly diverse populations are inevitably created with globalization. We posit that in multicultural contexts, effective therapeutic engagement requires therapists who are competent and confident to work with diversity and difference, utilizing insights into their own as well as their clients' internal and external worlds. Although there are many reasons why psychotherapies can be insensitive and harmful, for example, the inherent power imbalance in therapeutic relationships, a lack of awareness of cultural and ethnic variation and needs are among them. Acquisition of 'cultural competence' and increasing availability of culturally-adapted interventions should, in theory, enable practitioners to work with a range of individuals with whom they might have little in common. However, whilst cultural adaptation appears promising, there are concerns regarding its viability as a strategy for tackling disparities in access to psychological care. Evidence for cultural competency is patchy at best. We show how and why delivering effective psychotherapy in the twenty-first century requires a paradigm shift from current approaches to truly integrated models, developed in collaboration with recipients of care. Coproducing interventions, training, and means of evaluating them with clients necessitates taking into consideration social contexts, alternative conceptualizations of mental health and disorders and difficulties, and what constitutes appropriate helpful interventions for psychological distress. PRACTITIONER POINTS: Upskilling therapists to work with diversity and difference is essential for effective delivery of psychological treatments. Increasing the availability of culturally-adapted interventions together with therapists who are sufficiently competent and confident to deliver them should enable practitioners to work with a range of individuals with whom they might have little in common. Coproducing culturally appropriate means of responding to mental health difficulties, staff training and development, and service evaluation methods with clients necessitates taking into consideration social contexts, alternative explanatory models of mental health and 'illness', and what constitutes helpful interventions for psychological distress.

Intercultural communication through the eyes of patients: experiences and preferences

OBJECTIVES

To explore patients' preferences and experiences regarding intercultural communication which could influence the development of intercultural patient-centred communication training.

METHODS

This qualitative study is based on interviews with non-native patients. Thirty non-native patients were interviewed between September and December 2015 about their preferences and experiences regarding communication with a native Dutch doctor. Fourteen interviews were established with an interpreter. The semi-structured interviews took place in Amsterdam. They were focused on generic and intercultural communication skills of doctors. Relevant fragments were coded by two researchers and analysed by the research team by means of thematic network analysis. Informed consent and ethical approval was obtained beforehand.

RESULTS

All patients preferred a doctor with a professional patient-centred attitude regardless of the doctor's background. Patients mentioned mainly generic communication aspects, such as listening, as important skills and seemed to be aware of their own responsibility in participating in a consultation. Being treated as a unique person and not as a disease was also frequently mentioned. Unfamiliarity with the Dutch healthcare system influenced the experienced communication negatively. However, a language barrier was considered the most important problem, which would become less pressing once a doctor-patient relation was established.

CONCLUSIONS

Remarkably, patients in this study had no preference regarding the ethnic background of the doctor. Generic communication was experienced as important as specific intercultural communication, which underlines the marginal distinction between these two. A close link between intercultural communication and patient-centred communication was reflected in the expressed preference 'to be treated as a person'.