A Systematic Review of Interventions to Improve Initiation of Mental Health Care Among Racial-Ethnic Minority Groups
Abstract
Objective:
The objective of this systematic review was to identify interventions to improve the initiation of mental health care among racial-ethnic minority groups.
Methods:
The authors searched three electronic databases in February 2016 and independently assessed eligibility of 2,065 titles and abstracts on the basis of three criteria: the study design included an intervention, the participants were members of racial-ethnic minority groups and lived in the United States, and the outcome measures included initial access to or attitudes toward mental health care. The qualitative synthesis involved 29 studies.
Results:
Interventions identified included collaborative care (N=10), psychoeducation (N=7), case management (N=5), colocation of mental health services within existing services (N=4), screening and referral (N=2), and a change in Medicare medication reimbursement policy that served as a natural experiment (N=1). Reduction of disparities in the initiation of antidepressants or psychotherapy was noted in seven interventions (four involving collaborative care, two involving colocation of mental health services, and one involving screening and referral). Five of these disparities-reducing interventions were tested among older adults only. Most (N=23) interventions incorporated adaptations designed to address social or cultural barriers to care.
Conclusions:
Interventions that used a model of integrated care reduced racial-ethnic disparities in the initiation of mental health care.
Psychiatric conditions cause significant disability and cost more than $300 billion in the United States annually (1); yet, even for the most prevalent conditions, the majority of people in need of care do not receive effective, high-quality care (2). Shortages of mental health professionals, culturally divergent beliefs about the causes of mental illness, mistrust in the formal mental health system, negative attitudes about psychiatric treatment, and limited English proficiency contribute to disparities in mental health care for members of racial and ethnic minority groups (3–5). Between 2004 and 2012, racial-ethnic disparities in accessing mental health care increased in the United States, most prominently because of increased access to psychotropic medicine among whites, high uninsured rates among members of racial-ethnic minority groups, and difficulty detecting psychiatric distress among some members of minority groups (6).
Access to care comprises a complex set of attitudinal, behavioral, and resource-related factors, including availability, accessibility, affordability, and acceptability of health services as well as accommodation of services to patients’ needs (7). In addition, these factors interact with each other, creating additional layers of complexity. Although racial-ethnic disparities exist among high and low users of mental health services, much of the disparity appears to stem from lack of initial access to mental health services (8,9).
In the literature, episodes of mental health care are described as having a beginning, known as initiation; a middle, corresponding to the adequacy of follow-up visits; and an end, when treatment is terminated because of recovery or dropout (8–11). Evidence suggests that among African Americans and Latinos, disparities with whites have been greatest for the initiation of care compared with later episodes of care (9). According to these data, when there are racial-ethnic disparities in both the initiation and the adequacy of care, disparities related to adequacy of care appear to be less meaningful than those related to initiation. This suggests that intervening to improve the initiation of mental health care among racial-ethnic minority groups may reduce disparities. Equally important is understanding which interventions widen or fail to reduce disparities and the factors involved in their inefficacy.
The purpose of this systematic review was to synthesize current evidence on interventions intended to reduce racial-ethnic disparities in initial access to mental health care and summarize the extent to which the interventions were successful.
Methods
The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standard was used to ensure clarity and quality of the review (12). The first author (SL) wrote the systematic review protocol, including all screening and selection methods, and other authors (DC and PYC) revised and approved the protocol.
This systematic review did not involve recruitment and participation of human participants. An institutional review board was not involved, given that we examined publicly available published studies.
Inclusion and Exclusion Criteria
Studies that met the following criteria were included: the research sample consisted of members of racial-ethnic minority groups residing in the United States; the study design used an intervention that sought to improve the initiation of mental health care, rather than foster subsequent treatment, such as follow-up visits; and the study examined outcomes related to initial access, including visits to or new appointments with a mental health care provider, or willingness to initiate and actual initiation of interventions involving psychiatric medication or psychological treatment as a result of the study intervention. We restricted our search criteria to peer-reviewed journal articles written in English. We describe study selection criteria by population, intervention, and outcomes of interest.
Population.
The population of interest were members of racial-ethnic minority groups of all ages in the United States. We included participants with or without mental disorders, as long as a portion of participants had risk factors associated with mental disorders or symptoms or diagnoses of mental disorders. We included studies that compared outcomes between members of racial-ethnic minority groups and whites or studies that focused entirely on racial-ethnic minority groups.
Interventions.
We included interventions that sought to improve initial access to specialty mental health care, such as psychological counseling and pharmacological treatment. We also included interventions that sought to improve attitudes toward seeking mental health services. We included studies that assessed participants’ voluntary choice to initiate an appointment with a mental health provider. We excluded interventions that solely assessed follow-up visits to mental health services by participants from racial-ethnic groups, including interventions designed to improve adherence or quality improvement initiatives for ongoing mental health interventions.
Outcomes.
We included studies that measured initial access to mental health services, including visits to, or new appointments made for, consultation with a mental health care provider. Additional outcomes included pharmacological treatment initiation as a result of the study intervention and willingness to seek psychological or pharmacological treatment. Outcomes of interest were initiation of psychotherapy or pharmacologic treatment among participants motivated by a particular intervention, such as screening and referral, psychoeducation, or care coordination from a primary health clinic, school, nursing home, or homeless shelter. We excluded the studies in which care was initiated solely because of assignment to a mental health provider as part of the study protocol. In those cases, participants did not initiate care as a result of an intervention; rather they initiated care because they were assigned to receive care, and, therefore, study outcomes reflected other aspects of care.
Search Strategy
An informationist at the National Institutes of Health Library collaborated with the first author to develop the search strategy and filters. We conducted searches in February 2016 of the Medline (1946–2016), Scopus (1960–2016), and PsycINFO (1880–2016) databases. [A figure illustrating the search strategy is available as an online supplement .] A manual search of the bibliographies of included studies was conducted to identify additional studies for possible review.
Data Extraction
One author (SL) read all abstracts. Concurrently, additional authors and reviewers (JE, DC, and two research assistants) independently screened titles and abstracts of identified studies. On the basis of the screening of abstracts, three authors (SL, JE, and DC) read full texts of titles and abstracts from included records to assess eligibility. These authors discussed discrepancies in inclusion or exclusion of the articles after screening titles and abstracts and full texts. The authors also discussed discrepancies in low, unclear, and high risk of bias until they were resolved. If needed to achieve concordance, a third author not involved in the initial screening of abstracts or full texts (JE or DC) reviewed discrepant articles.
The flow diagram shows the number of articles identified from the electronic search and the number that were included and excluded [see online supplement ]. We included 29 studies. We counted the full texts of multiple articles as one study if the same interventions were administered to the same study population at a given time. We counted studies separately if two full texts presented the same intervention but one manuscript used only a subgroup of a larger study population. Two pairs of studies fell into this category. The study by Chinman et al. (13) used a subsample of the multisite study population described by Horvitz-Lennon et al. (14). Ayalon et al. (15) used data from a study by Areán et al. (16) and Bartels et al. (17) (Primary Care Research in Substance Abuse and Mental Health for the Elderly [PRISMe]) and used a subset of data from the full multisite study.
Authors categorized studies on the basis of type of intervention used to improve initiation of mental health service use among members of racial-ethnic minority groups. We further assessed the intervention characteristics by participant age, race-ethnicity, analyses of outcomes by racial-ethnic subgroup, categories of mental disorder, intervention settings, and disparities in access to care. We collected information on the significance of findings comparing outcomes before and after the intervention and information about comparison groups, where available, as evidence of intervention effectiveness. We defined statistical significance as a p value below .05.
Given the heterogeneity of interventions, outcomes, and participants’ demographic characteristics, as well as the low number of studies per intervention, we did not conduct a meta-analysis of results. We qualitatively synthesized the results based on groupings by intervention type.
Quality Appraisal
Authors used the Cochrane Collaboration’s tool for risk-of-bias assessment (18). We examined the domains of random-sequence generation, allocation concealment, participant blinding, blinding of outcome assessment, incomplete outcomes data, and other sources of bias. We categorized each risk-of-bias domain as low, high, or unclear on the basis of data reported in each study. For each article, we considered the overall risk of bias to be low if the risk of bias was low in all domains, high if the risk of bias was high in any domain, and unclear if information on risk of bias was unavailable.
Results
Study Characteristics
Table 1 shows the characteristics of the 29 included studies (33 full-text manuscripts). Three studies enrolled only women (19–21). Participants in eight studies were, on average, age 60 or older, and two studies focused on youths who were age 21 or younger. In the majority of studies, the study sample was made up primarily (over 70%) of one racial-ethnic group, including Hispanics or Latinos (N=11), African Americans (N=5), and Chinese Americans (N=3). Other studies included a mix of participants from various racial-ethnic minority groups. Studies consisting primarily or entirely of Latinos, African Americans, or Chinese Americans were likely to test psychoeducation interventions that improved mental health literacy, attitudes toward mental health services, and motivation to seek care (19,20,22–26).
| Characteristics of participants | ||||||||
|---|---|---|---|---|---|---|---|---|
| Intervention type and study | Location | Setting | N | Age | Race-ethnicity | Illness | Outcomes measured | |
| Policy change as natural experiment | ||||||||
| Adams et al., 2015 (33) | 35 states | Fee-for-service Medicare and Medicaid health services | 1,354 | <65 (65%); ≥65 (35%) | 70% whites; 15% African Americans; 12% Hispanics; 1% Asians; 1% Native Americans | Major depression and diabetes | Any antidepressant use per month | |
| Screening and referral | ||||||||
| Cohen et al., 2003 (27) | New York | Nursing homes | 123 | 82±9 | Primarily African Americans | Depression | Prescription for and receipt of antidepressants | |
| Rausch et al., 2012 (38) | New York | Pediatric and adolescent primary care practices | 636 adolescents; 41 providers | 13–20 | Primarily Latinos | Depressive symptoms | Provider attitudes toward depression screening and referral; patient willingness to be screened | |
| Psychoeducation | ||||||||
| Alvidrez et al., 2005 (22) | San Francisco | Geriatric health clinic | 69 | 71.4±6.4 | African Americans | Mood or anxiety disorders (59%) | Access to psychotherapy or psychosocial services; effect of psychoeducation on decision to start or stay in therapy; whether the ethnicity of the psychoeducator mattered | |
| Casas et al., 2014 (24) | San Diego | Community mental health agency | 93 | 38.0±11.6 | Latinos | na | Willingness to seek or recommend professional help | |
| Hernandez and Organista, 2013 (19) | San Francisco | Community clinic | 142 | 18–55 | Latinas | At risk of depression | Self-efficacy to identify need for treatment; decreased stigma; depression knowledge; intention to make appropriate health decisions; treatment history | |
| Lopez et al., 2009 (25) | Los Angeles | Church | 57 community residents; 38 family caregivers of persons with schizophrenia | Community residents (36.5±10.7); family caregivers (49.9±12.20 | Latinos | na | Community members' and caregivers' recommendation of professional mental health treatment | |
| Teng and Friedman, 2009 (26) | Houston | Church | 27 | 74.0±9.4 | Chinese Americans | na | Intention to consult with a mental health professional; help-seeking preferences | |
| Tran et al., 2014 (20) | Chatham, Durham, and Wake counties, North Carolina | Promotoras' social network (participants’ choice of location [home or quiet community space]) or by phone | 58 | Mean=38 (SD not reported) | Latinas (primarily Spanish speaking) | Depressive symptoms | Attitudes toward care | |
| Unger et al., 2013 (23) | Los Angeles | Community adult schools | 185 | 35.8±12.9 | Latinos | na | Stigma concerns about mental health care; confidence to identify depression; willingness to seek help | |
| Colocation of mental health services | ||||||||
| Areán et al., 2008 (16), and Bartels et al., 2004 (17) | 10 study sites (community health centers, hospital-based network, and U.S. Department of Veterans Affairs hospital) | Primary care setting | 2,022 | ≥65 | 51.7% whites; 24.7% African Americans; 14.7% Latino; 5.5% Asian; 3.4% other | Depression, anxiety, or drinking problem | Attended ≥1 mental health or substance abuse provider following primary care visit | |
| Ayalon et al., 2007 (15) | San Francisco | Primary care setting | 183 | ≥65 | 49% African Americans; 35% whites; 16% other | Depression, anxiety, or drinking problem | Attended ≥1 mental health or substance abuse provider following primary care visit | |
| Chong and Moreno, 2012 (39) | Tucson, Arizona | Community health center | 167 | 43±12 | Hispanics (primarily Mexicans) | Major depression | Making mental health appointments; patients’ willingness to pay for mental health services | |
| Kataoka et al., 2007 (34) | Los Angeles | School | 1,062 | 5–18 | 71% Latinos | na | Use of school-based mental health treatment | |
| Care or case management | ||||||||
| Boyd et al., 2015 (35) | Philadelphia | Community-based organization that addresses infant mortality and morbidity | 38 | 24±3.7 | 84.2% African Americans; 5.3% Latinos; 2.6% Asians; 7.8% patients with multiracial or multiethnic background | Major depression (84.2%); bipolar disorder and other mood disorders (13.2%) | Attended a behavioral health appointment | |
| Chinman et al., 2000 (13) | 15 sites in 9 metropolitan regions | Sites serving homeless adults | 1,340 | 38.4±9.4 | 53.1% African Americans; 46.9% whites | Major depression (50%); schizophrenia (35%); personality disorder (23%); anxiety disorder (20%); bipolar disorder (20%) | Use of psychiatric services | |
| Horvitz-Lennon et al., 2011 (14) | 18 sites in 9 metropolitan regions | Sites serving homeless adults | 6,829 | 38.5±9.4 | 49.7% African Americans; 5.6% Latinos, 44.7% whites | Depression, psychosis, mania, and disturbed behavior | Use of psychiatric services | |
| Uebelacker et al., 2011 (41) | Providence, Rhode Island | Primary care setting | 38 | Intervention (40.5±8.6); control (37.6±9.5) | Latinos | Depressive symptoms | Visits to outpatient provider for behavioral health; prescription of antidepressants | |
| Yeung et al., 2004 (40) | Boston | Community health center | 6,095 | 54±18 | Chinese Americans | Various psychiatric diagnoses, including major depression, anxiety disorders, adjustment disorder, and schizophrenia | Referral by primary care physician to behavioral health services | |
| Collaborative care | ||||||||
| Areán et al., 2005 (28) | 7 sites in North Carolina, Texas, Indiana, Washington, and California | Primary care | 1,801 | ≥60 | 77.1% whites; 12% African Americans; 8% Latinos (primarily Mexicans); 3% others | Major depression or dysthymia | Use of antidepressants and counseling | |
| Chung et al., 2014 (36), and Wells et al., 2013 (37) | Los Angeles | Mental health, primary care, substance abuse, and social services providers; faith-based programs; parks; hair salons; exercise clubs | 1,018 | 44.8±12.7 | 40.2% Latinos; 47.9% African Americans; 8.4% non-Hispanic whites; 3.4% others | Depressive symptoms | Behavioral health service use for outpatient, inpatient, and emergency room visits | |
| Cooper et al., 2013 (46) | Medically underserved neighborhoods in Maryland and Delaware | Urban, community-based primary care clinics | 132 patients; 27 primary care physicians | 18–75 | African Americans | Major depression | Receipt of depression treatment (antidepressants or counseling); patient attitudes on readiness for treatment; perceived effectiveness of antidepressants | |
| Ell et al., 2011 (44), and Ell et al., 2008 (45) | Los Angeles | Oncology clinics | 472 | ≥18 | 88% Hispanics | Depressive symptoms | Receipt of depression treatment (antidepressant or counseling) | |
| Ell et al., 2010 (42) | Los Angeles | Community public safety-net clinics providing diabetes care | 387 | ≥18 | 96% Hispanics | Depressive symptoms | Receipt of depression treatment (antidepressant or counseling) | |
| Joo et al., 2010 (29) | New York, Philadelphia, and Pittsburgh | Primary care clinics | 582 | ≥60 | 28% African Americans; 72% whites | Major and minor depression | Use of psychotherapy or health care services during 2-year follow-up | |
| Nicolaidis et al., 2013 (21) | Portland, Oregon | Domestic violence drop- in center | 59 | ≥18 | African Americans | Depressive symptoms | Attitudes toward depression; acceptability of antidepressants and mental health counseling | |
| Wells et al., 2012 (31), and Ngo et al., 2009 (32) | Los Angeles | Primary care clinics | 418 | 13–21 | 17.3% African Americans; 65.5% Hispanics or Latinos | Depressive symptoms | Use of specialty mental health care | |
| Wells et al., 2004 (30) | Multiple sites | Primary care practices | 1,356 | ≥18 | Whites, Latinos, African Americans | Depressive symptoms | Primary care or mental health specialty care visits; counseling; antidepressant use | |
| Yeung et al., 2010 (47) | Boston | Primary care setting | 100 | ≥18 | Chinese Americans | Major depressive disorder | Percentage treated by psychiatrists | |
Participants were recruited from health clinics (for example, a primary care, a geriatric health, and an oncology clinic) (N=18), non–health care or community-based settings (for example, a school, a church, and a domestic violence center) (N=11), multiple sources (N=2), and a nursing home (N=1). Seventeen studies focused on participants with mood disorders or symptoms (for example, depression, dysthymia, and bipolar disorder), six focused on various mental illnesses (a mix of mood disorders, anxiety disorders, and psychotic disorders), and six did not require participants to have a diagnosis. Ten studies investigated intervention outcomes for collaborative care, seven for psychoeducation, five for case management, four for colocation of mental health service in existing social or educational services, and two for screening and referral. One study was a natural experiment involving a policy change in Medicare Part D drug coverage.
Studies varied in the assessment of initiation of mental health care, our outcome of interest. Nineteen studies measured antidepressant use or psychotherapy with health professionals, 11 studies measured attitudes toward mental health care or knowledge of mental health, and two studies assessed referral to mental health services or making appointments for specialty care.
Racial-Ethnic Differences in the Initiation of Mental Health Care
Ten of the included studies examined racial-ethnic differences in initiation of mental health care in response to an intervention (14–17,27–34) (Table 2). Disparities decreased in response to the intervention in seven of the 10 studies, including four collaborative care interventions (29–32), two studies of colocation of psychiatric care in primary care settings (15–17), and one screening and referral intervention (27). The collaborative care intervention described by Joo and colleagues (29) led to a statistically significant decrease in disparities between African Americans and white older adults in use of psychotherapy. The remaining studies demonstrating reduction of disparities (N=6) did not test for statistically significant differences in outcomes between racial-ethnic groups (15–17,27,28,30–32). Those six studies demonstrated that members of racial-ethnic minority groups who participated in the intervention had improved access to care compared with those in the control group. Among white participants, there was little difference in outcomes between the intervention and control groups. All seven studies demonstrating disparities reduction showed that compared with whites, African Americans increased antidepressant use, visits to a mental health provider, psychotherapy use, or counseling (15–17,27–29,31,32). Four of the seven studies that demonstrated disparities reduction showed that compared with whites, Latinos increased mental health service use, antidepressant use, psychotherapy visits, or counseling visits after completing the integrated care or collaborative care intervention (16,17,28,31,32). Table 2 summarizes the intervention design and outcomes of all 29 studies, categorized by whether the study demonstrated disparities reduction.
| Intervention type and study | Intervention component | Racial-ethnic differences examined | Study design | Cultural adaptation | Outcomes |
|---|---|---|---|---|---|
| Evidence of disparities reduction | |||||
| Screening and referral | |||||
| Cohen et al., 2003 (27) | Depression screening and referral to a nursing home psychiatrist for diagnosis confirmation and treatment plan development | Yes | Controlled experimental trial | na | Patients in intervention group received more prescriptions of antidepressants after the intervention (p<.001); no pre-post difference in control group; no group difference in the total percentages of individuals who began or continued taking antidepressants; after intervention, significant increase in receipt of antidepressants among nonwhites (p=.002) |
| Colocation | |||||
| Ayalon et al., 2007 (15) | Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISMe); integration of mental health treatment into primary care clinics | Yes | Site-specific analysis of multisite randomized controlled trial | na | African-American older adults in intervention significantly more likely than the control group to visit providers of mental health or substance abuse services; no significant difference between intervention and control groups among white older adults; both African Americans and whites in intervention took less time to engage in first visit for mental health or substance abuse services after baseline evaluation |
| Collaborative care | |||||
| Areán et al., 2008 (16), and Bartels et al., 2004 (17) | PRISMe; integration of mental health treatment into primary care clinics; multisite, randomized controlled study | Yes | Multisite randomized controlled trial | na | Rate of mental health and substance abuse treatment access greater in integrated care versus enhanced referral model (p<.05); except for Asian older adults, participants more likely to access mental health or substance abuse services in the integrated care model, despite the availability of case managers linking two services; no significant interaction in overall analysis based on race-ethnicity; after controlling for mental distress, the analyses showed that Asians in integrated care had lower odds of accessing mental health care (p<.001), compared with the referral (control) group, whereas Latinos in integrated care group had 3.6 greater odds of accessing mental health or substance abuse care compared with those in the control group (p<.001). Whites, African Americans, and Latinos in integrated care had greater number of visits for mental health or substance abuse services, compared with those in the control group (p<.001). |
| Areán et al., 2005 (28) | Improving Mood–Promoting Access to Collaborative Treatment (IMPACT), a multisite, collaborative, stepped-care randomized trial for managing depression | Yes | Multisite, randomized controlled trial | Elderly people from various ethnic backgrounds were shown in the educational video and written materials | Participants from racial-ethnic minority groups in the intervention received more antidepressants or psychotherapy than those in the control group (p=.003 for antidepressants; p=.002 for psychotherapy), especially for Latinos (p=.015 for antidepressants; p=.005 for psychotherapy). Among African Americans, use of antidepressants was not statistically higher in the intervention group, but the use of psychotherapy increased among participants in the intervention compared with the control group (p=.001). |
| Joo et al., 2010 (29) | Prevention of Suicide in Primary Care Elderly, a group-randomized controlled trial comparing a primary care–based intervention with usual care to improve depression outcomes | Yes | Group-randomized controlled trial | na | African Americans with minor depression, but not with major depression, significantly less likely than whites to use psychotherapy (p<.05). African Americans in the intervention group more likely to use psychotherapy, but the difference did not reach statistical significance |
| Wells et al., 2012 (31), and Ngo et al., 2009 (32) | Youth Partners in Care (PIC), a quality improvement intervention in which case managers support primary care providers with patient evaluation, education, medication, and psychosocial treatment and linkage to specialty mental health services | Yes | Randomized controlled trial | Trained staff in cultural sensitivity issues and tailored examples to fit the cultural context of youth and family. Language compatibility | Youths in the intervention group significantly more likely to receive at least 6 specialty counseling visits or antidepressants in 6 months than the usual care group. Among African Americans, the intervention group used any psychotherapy or counseling from specialty or primary care significantly more than the control group (p=.036). Latinos had marginally significant improvement in specialty care access (p<.05). Other mental health service use patterns in primary care or use of medication not significant across race-ethnicity |
| Wells et al., 2004 (30) | PIC, a group-level, randomized controlled trial of quality improvement programs for depression with the use of collaborative care | Yes | Multisite randomized controlled trial | Physicians and patients from racial-ethnic minority groups were shown in video materials. Cognitive-behavioral therapy was developed for low-income members of racial-ethnic minority groups. Practices were provided bilingually. Staff trained in cultural sensitivity for depression treatment | PIC therapy significantly reduced unmet need for receiving antidepressants and psychotherapy among African Americans and Latinos. Use of medication marginally improved for African Americans and Latinos (p=.07). |
| No evidence of disparities reduction | |||||
| Natural experiment | |||||
| Adams et al., 2015 (33) | As part of Medicaid Part D, certain states lifted drug caps that had restricted the number of reimbursable prescriptions | Yes | Quasi-experimental trial | na | Antidepressant use increased for both whites and African Americans in states that omitted drug caps (p<.001) after implementation of Medicare Part D (p<.001). Disparities between whites and African Americans in antidepressant use increased in drug cap states (p<.01) because of increase in drug use among nonelderly whites. For non–drug cap states, antidepressant use slightly declined (p=.007) and disparities between whites and African Americans slightly decreased because of lower drug use among whites (p<.05). |
| Screening and referral | |||||
| Rausch et al., 2012 (38) | Depression screening by medical assistants at clinics, confirmed by primary care provider. Patient referral to mental health professionals, if necessary | No, minority group only | Single arm, pre-post | Spanish language for screening | Eighty screened patients (13%) were referred to mental health services. No baseline referral rate measured. Change in provider attitudes: discomfort or uncertainty in addressing adolescent depression decreased (p=.06); providers who could identify depression in their patients significantly increased (p<.05); significant increase in N of providers who felt that patients were comfortable addressing depressive symptoms with them (p<.05) and who felt that that they could make an urgent mental health appointment (p<.01) |
| Psychoeducation | |||||
| Alvidrez et al., 2005 (22) | Individual psychoeducation about psychotherapy entry and attendance tailored for older African Americans | No, minority group only | Historical comparison | Intervention developed from focus groups regarding perceptions of psychotherapy. Some racial-ethnic concordance between psychoeducators and patients | Similar proportion of patients starting therapy in both groups, but psychoeducation participants attended significantly more psychotherapy sessions. Qualitative interviews revealed that racial-ethnic concordance between psychoeducator and patient made no difference in helpfulness. Psychoeducation helped patients bring up concerns about treatment and discussion on ethnic, cultural, or religious issues |
| Hernandez and Organista, 2013 (19) | Fotonovela called Secret Feelings, a form of entertainment education to increase depression literacy, decrease stigma, and increase help-seeking knowledge and behavior | No, minority group only | Controlled experimental trial | Use of promotoras for Spanish language compatibility; reading the text out loud for illiterate participants | Depression knowledge improved significantly more in experimental group than control group. No difference in stigma toward mental health treatment between experimental and control groups. Antidepressant stigma decreased significantly in experimental compared with control group. Self-efficacy to identify need for treatment significantly increased among experimental versus control group. Experimental group had higher intention to seek treatment compared with control group, but the difference was not statistically significant |
| Unger et al., 2013 (23) | Fotonovela called Secret Feelings, a form of entertainment education to increase depression literacy, decrease stigma, and increase help-seeking knowledge and behavior | No, minority group only | Controlled experimental trial | Read the NIH low-literacy text pamphlet about depression, which conveys similar information without the narrative format | Depression knowledge significantly improved in experimental group versus control group. At 1-month follow up, group difference was even greater. Antidepressant stigma reduced significantly more in the experimental versus the control group, and the difference reached borderline significance at 1-month follow-up. Self-efficacy increased significantly for both groups and remained high at 1-month follow up. No group difference in the willingness to seek care |
| Casas et al., 2014 (24) | La CLAve (The Clue), a 35-minute psychoeducation program with the goal of increasing Spanish-speaking persons' literacy of psychosis | No, minority group only | Single arm, pre-post | Integrated popular cultural icons derived from music, art, videos, and mnemonic device | Postintervention: higher knowledge of psychosis (p<.001); increase in participants' attributions to psychosis in the hypothetical story (p<.001) and depression (p=.014); participants made more recommendations for professional resources (p<.001) and less to social resources (p<.001) |
| Lopez et al., 2009 (25) | La CLAve (The Clue), a 35-minute psychoeducation program with the goal of increasing Spanish-speaking persons' literacy of psychosis | No, minority group only | Single arm, pre-post | Spanish language for songs and stories | Community residents were less likely to suggest family members to seek personal solutions (p=.001) and more likely to suggest professional solution (p=.008). No significant changes in caregivers' recommended help seeking |
| Teng and Friedman, 2009 (26) | Educational community intervention to increase awareness of mental health and available resources | No, minority group only | Single arm, pre-post | Use of Mandarin; focus on mind-body connection | Attitudes about depression treatment improved significantly. Inclination to seek mental health professionals increased significantly. No difference in preferences for seeking out general physicians or spiritual counselors for help |
| Tran et al., 2014 (20) | Amigas Latinas Motivando el Alma/Latina (Friends of Motivating the Soul), promotora training and outreach to Latinas in their social network for mental health–resource sharing | No, minority group only | Single arm, pre-post | Outreach to promotoras' social network; use of Spanish language; incorporating perceptions and experiences of participants into core intervention components | Modest improvement in attitudes about depression treatment postintervention, suggesting community-level stigma reduction |
| Colocation | |||||
| Chong and Moreno, 2012 (39) | Psychiatrists providing telepsychiatry services at a community health center | No, minority group only | Randomized controlled trial | Project recruiter was Mexican American; bilingual Hispanic psychiatrists provided telepsychiatry; easily accessible to public transportation; undermined stigma due to provision of depression treatment in a medical clinic | Intervention participants significantly more likely to make mental health appointments and use antidepressants. More intervention than control group participants were willing to pay the same or more for telepsychiatry than for a primary care visit |
| Kataoka et al., 2007 (34) | Youth suicide prevention program, a school-based program that trains school staff as crisis team members | Yes | No control, program evaluation | na | Of 68 parents whose children used a school gatekeeper training program for suicide prevention, 50 (53%) used community mental health services and 37 (39%) used school mental health services. Latino students had lower rates of using community mental health services compared with non-Latinos, but there was no difference in school-based mental health service use |
| Care management | |||||
| Boyd et al., 2015 (35) | Behavioral health referral intervention. Referral to improve access to care based on identification of barriers, effective solutions, and systematic follow-up. Case management with the addition of specific psychoeducation modules | No | Single arm, pre-post | Reminder calls, facilitated transportation, and case manager available to attend appointment | Twenty-nine (76%) women scheduled an appointment for behavioral health treatment and 21 (55%) attended a behavioral health appointment by the postintervention follow-up |
| Chinman et al., 2000 (13) | Access to Community Care and Effective Services and Support (ACCESS), a federally funded demonstration of the effectiveness of a systems-integrating strategy using assertive community treatment for homeless adults with mental illness | No | No control, program evaluation | Clinician-client racial matching for African Americans and whites | Significant improvement in the reception of psychiatric care at follow-up. No significant difference in access to outpatient psychiatric service by racial concordance of case managers and clients |
| Horvitz-Lennon et al., 2011 (14) | ACCESS (see above) | Yes | No control, program evaluation | Clinician-client racial matching for African Americans and whites | Probability of using psychiatric care increased over time but did not differ across race-ethnicity |
| Uebelacker et al., 2011 (41) | Depression Health Enhancement for Latino Patients, a telephone depression care management intervention | No, minority group only | Randomized controlled trial | Instruments available in Spanish; bilingual/bicultural depression care managers chosen for their professionalism and warmth | No group difference in the number of outpatient visits for behavioral health or the use of antidepressant medications. During posttreatment, there was a trend for the intervention group to have fewer days of antidepressant use (p<.10). |
| Yeung et al., 2004 (40) | South Cove Bridge Project, colocation of collaboration between mental health services and primary care, with a primary care nurse as care manager | No, minority group only | Historical comparison | Training of primary care physicians (PCPs) and nurses in cultural sensitivity, including discussion of Asian Americans' common illness beliefs, help-seeking behaviors, and attitudes toward mental disorders and mental health services. Handouts with nonstigmatizing translations of psychiatric terminologies. The PCPs and nurse had opportunities to rehearse how to explain mental disorders to patients without eliciting resentment | PCPs referred 64 clinical patients (1.1%) to mental health services, a 60% increase (p<.05) in the percentage of clinic patients referred in the previous year; 81% of patients referred during the project received psychiatric evaluation, compared with 53% (p<.001) in the previous year |
| Collaborative care | |||||
| Cooper et al., 2013 (46) | Blacks Receiving Interventions for Depression and Gaining Empowerment. Compared standard collaborative care with a patient-centered and culturally tailored collaborative care intervention | No, minority group only | Cluster-randomized controlled trial | Tailored collaborative care management focused on access barriers, social context, and patient-provider relationship for participants and participatory communication skills training and mental health consultation for providers | Patient attitudes to readiness for treatment were significantly higher in standard compared with tailored collaborative care group (p=.02). Perceived effectiveness of antidepressants was higher among standard compared with tailored collaborative care group (p=.06). N of patients taking any antidepressants remained low regardless of intervention assignment. Reception of any counseling marginally significantly increased for tailored group pre- and postintervention, but no pre-post difference found for standard collaborative care group. Receipt of any treatment marginally increased over time for standard group but not for tailored group. Significant increase in receipt of guideline-concordant pharmacotherapy and psychotherapy (p=.049 and p=.07 respectively) for standard collaborative care group while only marginal increase in receipt of psychotherapy (p=.05) for tailored collaborative care group. Between-group comparisons from baseline to 12 months not statistically significant for any type of depression treatment |
| Ell et al., 2011 (44), and Ell et al., 2008 (45) | Alleviating Depression Among Patients with Cancer (ADAPt-C), adapted from IMPACT, a collaborative, stepped-care model | No, minority group only | Randomized controlled trial | Bilingual social workers and problem-solving therapy aligned with perceived stress-related needs and cultural values aimed at stigma reduction | Patients in ADAPt-C group received significantly greater depression treatment (N=10, antidepressants; N=94, psychotherapy; N=71, both) compared with the control group (N=13, antidepressants; N=4, psychotherapy; N=7, both) (p<.001). At 1-year follow-up, patients with recurrence of major depression in the intervention group significantly more likely to receive depression treatment compared with patients with major depression in control group (p=.03). At 1-year follow-up, enhanced care group compared with intervention group had significantly greater receipt of antidepressants, likely because of oncologists’ being informed of patient depression status. No difference in receipt of antidepressants or counseling observed at 2-year follow-up |
| Ell et al., 2010 (42) | Multifaceted diabetes and depression program (MDDP), socioculturally adapted collaborative care with a stepped-care treatment algorithm | No, minority group only | Randomized controlled trial | Bilingual social workers and problem-solving therapy aligned with perceived stress-related needs and cultural values aimed at stigma reduction | At 1-year follow up, MDDP patients significantly more likely to receive antidepressants than patients in control group (p=.02). No significant difference in the receipt of psychotherapy or counseling between intervention and control groups |
| Nicolaidis et al., 2013 (21) | The Interconnection Project, a community-based, chronic care management intervention for African-American survivors of interpersonal violence. A peer health advocate served as a care manager and used motivational interviewing to help women set and meet self-management goals | No, minority group only | Single arm, pre-post | Program based within a partnering community agency and led by a health advocate | Attitudes about depression significantly improved after intervention (p=.02) and use of counseling marginally improved (p=.05). No difference in seeking depression care, using antidepressants, acceptability of antidepressants, and acceptability of counseling |
| Chung et al., 2014 (36), and Wells et al., 2013 (37) | Community Partners in Care, a group-level, randomized comparative effectiveness trial of Community Engagement and Planning (CEP) to implement depression care quality improvement | No | Group-randomized controlled trial | Collaborative planning and implementation across community programs; diverse agencies encouraged to develop a strategy and training plan to jointly provide care for depression | CEP reduced behavioral health hospitalization compared with control group (p<.05). No statistically significant difference shown in the rate of ≥2 emergency room visits by intervention status. Any primary care or public health depression visits or specialty care visits (psychiatrists and mental health providers) did not differ significantly by intervention status; 6-month (short-term) effect on decreasing the use of behavioral health hospitalization in CEP (p<.05) but less evident effect at 12 months |
| Yeung et al., 2010 (47) | Culturally sensitive collaborative treatment (CSCT). A cultural component was added to the collaborative management model | No, minority group only | Randomized controlled trial | Used engagement interview protocol, a culturally sensitive psychiatric assessment, to explore patient's illness beliefs | No significant difference in stigma score and percentage treated by psychiatrists between intervention and control groups. Before CSCT intervention, 7% of patients who were screened for depression received psychiatric treatment; after CSCT intervention, 43% of those screened positive for depression engaged in psychiatric assessment (a nearly sevenfold increase) |
Three of the ten studies that examined racial-ethnic differences in outcomes reported increased disparities after the intervention. Adams et al. (33) found that lifting drug caps in states that had restricted the number of reimbursable prescriptions created wider disparities between African Americans and whites (p<.05). Kataoka et al. (34) assessed rates of initiating community- and school-based mental health services after receipt of a school-based suicide gatekeeper program. Latino students initiated community services at lower rates compared with non-Latino students, but there was no racial-ethnic difference in accessing school-based mental health services. Areán et al. (16) and Bartels et al. (17) found that Asians assigned to an integrated care group used fewer mental health and substance use services compared with other racial-ethnic groups. Horvitz-Lennon and colleagues (14) showed that disparities in access to mental health services among clients who were homeless did not change after participation in the Access to Community Care and Effective Services and Support (ACCESS) intervention.
Three of the 19 studies that did not examine racial-ethnic differences in outcomes enrolled participants primarily from a mix of racial-ethnic minority groups (13,35–37) (Table 2). These studies showed improvement in attendance of mental health clinics and reduced psychiatric hospitalization rates. Sixteen of the 19 studies that did not measure racial-ethnic differences in outcomes were unable to do so because the participants were entirely or primarily members of the same racial-ethnic minority group.
Cultural Adaptation
Of the 29 included studies, 23 incorporated some level of social, cultural, or linguistic adaptation of the intervention (Table 2). These adaptations involved incorporating feedback from participants from racial-ethnic minority groups on intervention design, hiring culturally and linguistically compatible interventionists, using images and phrases that fit participants’ cultural context, training providers in cultural sensitivity, meeting practical needs (such as appointment reminders and transportation), or modifying the intervention to align with participants’ conceptualization of mental health (for example, the belief in a connection between mind and body). Three of the seven interventions that demonstrated reduction in disparities used cultural adaptation, such as referencing diverse ethnic backgrounds in educational materials, training staff in culturally sensitive issues in depression treatment, and providing the interventions bilingually. Twenty of the 22 studies that did not demonstrate reduction in disparities used varying degrees of cultural adaptation, and all of the psychoeducation studies (N=7) were adapted culturally or linguistically.
Mental Health Interventions
Policy change as a natural experiment.
After implementation of Medicare Part D, the federal program that subsidizes the costs of prescription drugs and the drug insurance premium for Medicare beneficiaries, restrictions on the number of reimbursable prescription medications that Medicare enrollees could receive per month were removed in some states (that is, drug caps were lifted). Adams et al. (33) analyzed health insurance claims and enrollment data for a nationally representative sample of Medicare and Medicaid dual enrollees with comorbid depression and diabetes across 35 states. Receipt of antidepressants increased for both whites and African Americans in states that lifted drug caps, compared with states that had no change in prescription reimbursement policy. However, disparities in the receipt of antidepressants between African Americans and whites increased in states that removed drug caps because of increased receipt of antidepressants among nonelderly white patients.
Screening and referral.
Social workers and primary care providers were trained to screen for depression in nursing homes and primary care clinics (27,38). Nursing home patients were more likely to receive antidepressant prescriptions in study sites that had implemented mandatory screening (27). Screening reduced disparities in the receipt of antidepressants between African-American and white older adults (p<.05). Willingness to be screened for depression increased in primary care practices, which treated mainly Latino adolescents (38). Screening was provided by medical assistants and was followed by symptom confirmation by primary care providers.
Psychoeducation.
The seven psychoeducation interventions aimed to educate patients about psychotherapy entry and attendance, improve depression or psychosis literacy, reduce stigma associated with antidepressants, and increase access to help seeking or available mental health resources (19,20,22–26). Participants were mainly recruited from primary care clinics or community organizations (such as community clinics, schools, or churches). All psychoeducation studies consisted entirely or primarily of racial-ethnic minority groups and did not have a racial-ethnic comparison group. Most of the interventions were delivered in one session. All psychoeducation interventions were culturally or linguistically modified by using varied approaches. Interventions used promotoras or Spanish-speaking individuals for education and data collection, developed the intervention based on the target population’s perception of depression (for example, the belief among Chinese Americans in a mind-body connection), and incorporated photographs, scripts, and cultural icons familiar to members of racial or ethnic minority groups.
Psychoeducation improved the frequency with which patients raised concerns about treatment and discussion of ethnic, cultural, and religious issues (22). It also improved knowledge about depression or psychoses (19,23–25), reduced stigma associated with antidepressants (19,23), improved attitudes about depression treatment (20,26), and increased participants’ willingness to recommend seeking professional mental health services (24).
Colocation of mental health services.
Mental health services were provided in primary care clinics as part of the PRISMe project (15–17). This multisite, randomized controlled trial compared an integrated care intervention with an enhanced-referral model in which psychiatric services were provided in a separate location. The services in the primary care setting included assessment, care planning, counseling, case management, psychotherapy, and pharmacological treatment. The PRISMe studies showed that Latinos and African Americans in the integrated care group were more likely to seek mental health providers compared with Latino and African Americans in the enhanced-referral group. Among whites, there was no change in seeking mental health care by treatment condition. Asians who received integrated care were significantly less likely to initiate mental health care compared with Asians in the control group. However, there were no statistically significant differences in care initiation outcomes by treatment condition when race-ethnicity was used as an interaction term.
Chong and Moreno (39) found that providing telepsychiatry at a community health center increased mental health appointments, antidepressant use, and willingness to pay for telepsychiatry among Latinos. Kataoka et al. (34) reported that a school-based youth suicide prevention program that trains school staff as crisis team members improved help seeking from community mental health services; however, Latino students were less likely than non-Latino students to seek care from community mental health services. There was no racial-ethnic difference in the use of school-based mental health services.
Care or case management.
Of five studies involving care or case management, two reported findings from the ACCESS program, a federally funded demonstration of the effectiveness of a systems-integrating strategy using assertive community treatment (ACT) for homeless adults with mental illness (13,14). ACT provides intensive case management and includes a multidisciplinary team approach, frequent and intensive contacts, small caseloads, and assertive outreach. In both studies, the investigators found significant improvement in the receipt of psychiatric care at 12 months and over time, but initiation of psychiatric care did not differ by race-ethnicity.
The Sandy Cove Bridge Project provided cultural sensitivity training to nurses and primary care practitioners treating Chinese-American patients (40). Elements of the training included common illness beliefs and attitudes toward mental disorders and mental health service use. The providers rehearsed explaining mental disorders to patients without eliciting resentment. The intervention led to increased referrals for psychiatric evaluation and greater acceptance of referrals by the patients.
Uebelacker et al.’s (41) telephone-based care management intervention for Latinos with depressive symptoms resulted in no difference in outpatient visits or receipt of antidepressants between the intervention and the control groups. Boyd and colleagues (35) showed that a behavioral health referral intervention based on identification of barriers, effective solutions, systematic follow-up, and psychoeducation with a case manager led to improvement in scheduling appointments for mental health services and in appointment attendance.
Collaborative care.
The Prevention of Suicide in Primary Care Elderly: Collaborative Trial was the only study that showed a statistically significant reduction of racial disparities in psychotherapy use between African Americans and whites with minor depression after the participants completed the primary-care based intervention (29), which was intended to improve depression outcomes. No reduction was found in racial disparities in access to care among participants with major depression.
Three collaborative care interventions, all administered mainly in primary care settings, reduced racial-ethnic disparities in the receipt of antidepressants or psychotherapy, although the results were not statistically significant. The Improving Mood–Promoting Access to Collaborative Treatment (IMPACT) study, a multisite, randomized trial of a collaborative, stepped-care treatment for depression, found reduced disparities in receipt of antidepressants or psychotherapy visits among participants from racial-ethnic minority groups, especially Latinos (22). Among African Americans, participants in the IMPACT group improved in initiating psychotherapy but not in receipt of antidepressants compared with the control group.
Wells and colleagues (30) conducted a five-year follow up of Partners in Care (PIC), a quality improvement intervention in which case managers support primary care providers with patient evaluation, education, medication, psychosocial treatment, and linkage to mental health services. PIC marginally improved receipt of psychotropic medications among African Americans and Hispanics. Youth PIC, for participants between the ages of 13 and 21, reduced disparities in use of psychotherapy or counseling among African-American and Latino children and young adults compared with usual care (31,32).
Community Partners in Care (CPIC) was a group-level, randomized, comparative-effectiveness trial of Community Engagement and Planning, a community-engaged depression quality improvement program. The study took place in community-based settings with vulnerable populations with depression, including mental health and substance abuse services, faith-based programs, hair salons, and exercise clubs. Participants were primarily African Americans and Latinos. The intervention reduced hospitalizations for behavioral disorders among African Americans and Latinos at six-month follow-up, whereas the initiation of outpatient and specialty care visits did not change (36,37). However, the reduction in hospitalizations for behavioral disorders for African Americans and Latinos was less evident at 12-month follow-up.
Alleviating Depression Among Patients with Cancer (ADAPt-C), adapted from the collaborative, stepped-care IMPACT model, took place in community public safety-net and oncology clinics (42–45). In ADAPt-C, a cancer-depression clinical specialist provides psychotherapy in addition to care management under psychiatrist supervision. Compared with patients who received enhanced usual care, the intervention group received more depression treatment and were more likely to receive treatment at one-year follow-up if major depression recurred. At two-year follow-up, however, there was no difference between the groups in the receipt of antidepressants or counseling. Among Latino patients with diabetes and depression at one-year follow up, those in the intervention group was more likely than the control group to receive antidepressants, although no difference was seen in the receipt of psychotherapy.
Two collaborative care interventions, both with sample sizes under 150, were administered in primary care settings. The Blacks Receiving Interventions for Depression and Gaining Empowerment (BRIDGE) study compared a standard model of collaborative care for depression with a patient-centered and culturally tailored collaborative care intervention (46). All participants were African American. The BRIDGE intervention marginally improved patient attitudes towards readiness for depression treatment; however, it did not change receipt of antidepressants. In another study, Chinese-American adults received Culturally Sensitive Collaborative Treatment, which uses culturally sensitive psychiatric assessment to explore patients’ illness beliefs. The intervention improved uptake of psychiatric assessment but did not reduce stigma (47).
Risk of Bias Assessment
Fifteen studies had a low risk of bias (Table 3). Most (N=12) studies with a low risk of bias were randomized controlled trials of collaborative care or colocation of mental health services. One natural experiment arising from a change in Medicare medication reimbursement policy and two studies with a historical control group (a study of psychoeducation and a study of case management) also had a low risk of bias.
| Risk of bias | |||
|---|---|---|---|
| Intervention type | Low | Unclear | High |
| Collaborative care | 9 | 0 | 1 |
| Psychoeducation | 1 | 1 | 5 |
| Case management | 1 | 1 | 3 |
| Colocation of mental health services | 3 | 0 | 1 |
| Screening and referral | 0 | 0 | 2 |
| Medicaid policy change as a natural experiment | 1 | 0 | 0 |
a
Risk of bias was assessed for several domains, including random-sequence generation, allocation concealment, participant blinding, blinding of outcome assessment, incomplete outcomes data, and other sources of bias. Risk of bias was categorized as low if the risk of bias was low in all domains, high if the risk of bias was high in any domain, and unclear if information on the risk of bias was unavailable.
The most common reason for a high risk of bias was the absence of a control group. Ten studies lacked a control group. In addition, two randomized controlled trials of psychoeducation had a high risk of bias because of other methodological concerns. Two randomized controlled trials had an unclear risk of bias because of incomplete data about allocation concealment or blinding.
Discussion
This systematic review synthesized current evidence about interventions intended to improve initiation of mental health services among racial-ethnic minority groups and assessed the extent to which these interventions were effective. Of the 29 studies that met inclusion criteria, seven studies provided evidence that screening and referral, colocation of primary care and mental health services, and collaborative care interventions not only improved mental health outcomes but also contributed to disparities reduction in initiation of care. Notably, six of the seven interventions that reduced racial-ethnic disparities in initiation of mental health services primarily used an integrated care model. Each of the six interventions resulted in increased uptake of psychotherapy or antidepressant use among members of racial-ethnic minority groups compared with white participants.
The case for promoting integrated mental health care in primary care settings is well established (48–50). This model may have particular benefits for disparities reduction, also. The practical convenience and privacy in seeking care for mental illness in these settings may enhance help seeking by members of racial-ethnic minority groups (51). A study of African-American primary care users suggested that primary care settings could provide exposure to mental health services that familiarize people with mental health care, allowing African-American patients to “try before they buy” (52). Integrated care settings may also provide a greater variety of providers who deliver mental health services, thus extending services in racial-ethnic minority communities. These providers played an integral role in many of the interventions we reviewed. Depression screening by medical assistants, social workers, and primary care doctors improved receipt of antidepressants, provider attitudes toward depression identification, and patient attitudes toward screening (27,38). In communities with large populations from racial-ethnic minority groups and shortages of mental health providers, telepsychiatry also may extend access to mental health care in community and primary care settings. However, implementation of telepsychiatry faces numerous legal, ethical, and logistical challenges, despite evidence of its effectiveness and potential for reducing disparities (53).
More than one-third of the included studies involved collaborative care interventions, which have been shown to improve access to mental health care and clinical outcomes among racial-ethnic minority groups (54). In fact, the body of evidence supporting the effectiveness of collaborative care for treatment of minority groups is larger than for any other intervention. Recent policy changes make nationwide dissemination and implementation of collaborative care increasingly likely. The Centers for Medicare and Medicaid Services modified the physician fee schedule to reimburse physician and nonphysician providers of collaborative care model in clinical practice (55). In our included articles, several components of collaborative care appeared to be effective in improving initiation of treatment among racial-ethnic minority groups, including management of mental illness in primary care settings, use of culturally and linguistically sensitive psychoeducational materials for patients, and encouraging the use of psychotherapy to patients in need.
The challenge of reducing disparities in mental health care initiation will necessarily encompass more than implementation of effective models of care. Access to care involves understanding the interplay of context, illness characteristics and course, social networks, and systems of care, and the factors that predict disparities in initiation of care operate at multiple levels (for example, individual, neighborhood, and policy levels) (56,57). Being educated, living in an urban area, being female, and having mental and general medical complaints all predict greater initiation of care, whereas being black or Latino, being publicly insured, not being a citizen, and being healthier predict less initiation (57). Indices of disadvantage, such as living in a neighborhood with fewer college-educated residents, are associated with less initiation of mental health care. Even in settings where the density of mental health care providers may be greater, provider preferences, insurance coverage, and population perceptions of the services may explain low initiation of care among racial and ethnic minority groups (57). These findings suggest that efforts to influence health policies (for example, policies affecting insurance coverage and reimbursement) and social policies that reduce disadvantage could contribute to disparities reduction and that these efforts should be pursued simultaneously with efforts to expand the delivery of clinical interventions.
Among the contextual factors that influence initiation of mental health care, reducing cultural and social barriers to mental health care could also facilitate initiation of care and thereby reduce disparities, although evidence of the effectiveness of this approach is limited (58). Twenty-three of 29 studies in our sample mentioned using some form of cultural adaptation as part of their intervention. Of the seven interventions associated with reduced disparities in access to care, three studies involved interventions that had been culturally and linguistically adapted and four studies did not mention cultural adaptation. Many interventions, especially psychoeducation interventions, used scripted stories and visual representations to depict mental illness among members of participants’ own racial-ethnic groups. Other studies in our sample incorporated clients’ illness beliefs in culturally sensitive training of providers. However, these studies lacked comparison groups, and the added benefits of cultural adaptation for disparities reduction were not assessed. There is little question that providing psychoeducation or counseling in a client’s preferred language is effective for those with limited English proficiency. It is likely that using a more comprehensive, personalized approach to understanding clients’ values, preferences for care, and perceptions of need as well as facilitating communication with providers could more effectively reduce barriers and disparities associated with care initiation (59).
Although this systematic review fills an important gap, it had several limitations. First, the included studies were heterogeneous, and we were unable to conduct a meta-analysis of results and effect sizes. The interventions were diverse in terms of type, setting, sample size, and severity of symptoms or diagnoses. Second, our target outcome, the initiation of mental health services, was sometimes difficult to ascertain. Many studies with multiple outcomes did not make a clear distinction between initial access to mental health care and subsequent follow-up visits (quality improvement or engagement). Third, few studies (only 10) recruited both members of racial-ethnic minority groups and whites or another comparison group, thus allowing for measurement of disparities within the sample. Fourth, the populations represented in this review included African Americans, Latinos, whites, and Chinese Americans. There was no explicit inclusion of other underrepresented minority groups, such as American Indians or Native Hawaiian or Pacific Islanders. These limitations have been echoed in other reviews of populations at risk of mental health care disparities (60).
Conclusions
To our knowledge, this is the first systematic review that applies rigorous methodology to report on interventions that can potentially reduce racial-ethnic disparities in the initiation of mental health care. We found evidence that integrated care models hold promise in reducing these disparities. Importantly, effective interventions to reduce disparities in care must be widely disseminated and implemented to be of value.
This knowledge could be enhanced by studies that examine the mechanisms of disparities reduction as well as alternative models of integration, such as the use of eHealth or mHealth technologies. At the same time, we note that the current disparities literature could be strengthened by improving meaningful inclusion of participants from racial-ethnic minority groups and by conducting subgroup analyses when assessing intervention outcomes. An examination of how to study and implement interventions that target multiple levels of predictors of poor access would enable a more holistic approach to disparities reduction. The lack of clear policies and guidelines for reduction of mental health care disparities is partially due to the dearth of published studies on effective interventions targeting the complexity of factors affecting access to care among racial-ethnic minority groups.
Acknowledgments
The authors thank Douglas Joubert, M.S., M.L.I.S., and Katherine Baldwin, B.A., for participating in screening of titles and abstracts. They also thank Mr. Joubert for providing electronic database searches.
Supplementary Material
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Information & Authors
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Cover: Sea Grasses and Blue Sea, by Milton Avery, 1958. Oil on canvas. Gift of friends of the artist, Museum of Modern Art, New York. Digital image © The Museum of Modern Art/Licensed by SCALA/Art Resource, New York. © The Milton Avery Trust/Artists Rights Society, New York.
History
Received: 31 August 2017
Revision received: 12 January 2018
Accepted: 27 February 2018
Published online: 2 May 2018
Published in print: June 01, 2018
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Competing Interests
The authors report no financial relationships with commercial interests.
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