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Issues of cultural competence in mental health care

Published:October 21, 2020DOI:https://doi.org/10.1016/j.japh.2020.10.015

      Abstract

      As the United States’ population continues to grow in its diversity, health care providers, including pharmacists, need to be able to provide culturally competent care to their patients. Cultural competence allows patients to feel comfortable with their provider and leads to their continuing to seek out care. Mental health is one of the most underused services in health care, particularly in underrepresented minority communities. This review looks at different published literature that assessed the reasons why individuals from minority communities may avoid seeking mental health care, cultural competence in psychiatric care for underrepresented minority communities, strategies for implementation for training providers in cultural competency, and barriers to implementation in mental health services. Current ideas include providing cultural competency training to students in their respective professional school or residency, incorporating the cultural formulation interview into psychiatric sessions, or increasing minority representation in the psychiatric services. On the basis of the literature examined, research is still needed to identify the best approach to improve culturally competent care in psychiatric services in the United States.
      The U.S. Census estimates that by 2044 people from racial minority communities will comprise more than 50% of the population, making the United States a majority-minority nation.
      • Colby S.L.
      • Ortman J.M.
      Projections of the size and composition of the U.S. population: 2014 –2060.
      As the United States continues to grow more diverse in population, health care providers, including pharmacists, will have to be competent in treating a culturally diverse patient population. Currently, however, individuals from minority communities continue to experience health disparities in all aspects of their health care, notably mental health services.
      • Burgess D.J.
      • Ding Y.
      • Hargreaves M.
      • Van ryn M.
      • Phelan S.
      The association between perceived discrimination and underutilization of needed medical and mental health care in a multi-ethnic community sample.
      Although these inequalities in health care existed before coronavirus disease (COVID-19), they have increased since the pandemic began owing to certain ethnic groups being disproportionately affected by COVID-19 as well as the limited access to services and culturally competent providers.

      Stephenson J. CDC report reveals “considerably elevated” mental health toll from COVID-19 stresses [e-pub ahead of print]. JAMA Health Forum. https://doi.org/10.1001/jamahealthforum.2020.1078, accessed November 1, 2020.

      ,
      • Smith K.
      • Bhui K.
      • Cipriani A.
      COVID-19, mental health and ethnic minorities.
      Despite the American Psychological Association (APA) and Association for Multicultural Counseling and Development recognizing the importance of cultural competency, evidence is lacking regarding how to develop culturally competent guidelines.
      • Whaley A.L.
      • Davis K.E.
      Cultural competence and evidence-based practice in mental health services: a complementary perspective.
      For this commentary, cultural competency will be defined as a set of interpersonal skills that allow health professionals to understand and appreciate individuals of different backgrounds and provide culturally appropriate services to diverse populations.
      • Bhui K.
      • Warfa N.
      • Edonya P.
      • Mckenzie K.
      • Bhugra D.
      Cultural competence in mental health care: a review of model evaluations.
      ,
      • Mian A.I.
      • Al-Al-Mateen C.S.
      • Cerda G.
      Training child and adolescent psychiatrists to be culturally competent.
      In addition, this review will focus on culturally competent care in underrepresented minority communities (black, Asian, Hispanic or Latino, Native American, or Pacific Islander) and will not include other underserved or vulnerable populations (such as lesbian, gay, bisexual, transgender, or queer+ patients; people with disabilities; seniors; or rural patients) that experience health disparities.
      Although mental health disorders affect all people, evidence shows that individuals from minority communities are less likely to have adequate access, seek help, and be diagnosed.
      • Bhui K.
      • Warfa N.
      • Edonya P.
      • Mckenzie K.
      • Bhugra D.
      Cultural competence in mental health care: a review of model evaluations.
      Because patients from minority communities are often excluded from mental health research studies, diagnostic assessments are not sensitive for minority populations.
      • Burgess D.J.
      • Ding Y.
      • Hargreaves M.
      • Van ryn M.
      • Phelan S.
      The association between perceived discrimination and underutilization of needed medical and mental health care in a multi-ethnic community sample.
      ,
      • Trinh N.T.
      • Bernard-negron R.
      • Ahmed I.I.
      Mental health issues in racial and ethnic minority elderly.
      ,
      • Johnson J.L.
      • Cameron M.C.
      Barriers to providing effective mental health services to American Indians.
      Furthermore, patients from minority communities have been found to have variable cytochrome P450 expression compared with white patients, suggesting altered response to psychopharmaceuticals,
      • Silva H.
      Ethnopsychopharmacology and pharmacogenomics.
      although extensive research has not been performed, and there is a lack of consensus on the application of pharmacogenomics to guide psychotropic treatment. Moreover, they have less access to mental health services in their communities and are less likely to receive the appropriate treatment for their mental disorder.
      • Burgess D.J.
      • Ding Y.
      • Hargreaves M.
      • Van ryn M.
      • Phelan S.
      The association between perceived discrimination and underutilization of needed medical and mental health care in a multi-ethnic community sample.
      ,
      • Johnson J.L.
      • Cameron M.C.
      Barriers to providing effective mental health services to American Indians.
      ,
      • Stewart S.M.
      • Simmons A.
      • Habibpour E.
      Treatment of culturally diverse children and adolescents with depression.
      In addition, patients of different cultures have a diverse way of expressing symptoms of mental illnesses, making accurate diagnosis difficult.
      • Johnson J.L.
      • Cameron M.C.
      Barriers to providing effective mental health services to American Indians.
      ,
      • Stewart S.M.
      • Simmons A.
      • Habibpour E.
      Treatment of culturally diverse children and adolescents with depression.
      Evidence has also shown that the perceived discrimination may lead to reduced use of health care services.
      • Burgess D.J.
      • Ding Y.
      • Hargreaves M.
      • Van ryn M.
      • Phelan S.
      The association between perceived discrimination and underutilization of needed medical and mental health care in a multi-ethnic community sample.
      When combined with a mental illness, these populations deal with double stigma from their health care providers. Mental health stigma was described in 1 study that found that pharmacists had lower willingness to provide pharmacy services to those with mental illnesses and felt uncomfortable discussing psychotropic medications, which may be attributed to inadequate knowledge of mental health conditions and a belief that these patients may have unstable behaviors.
      • O’reilly C.L.
      • Bell J.S.
      • Kelly P.J.
      • Chen T.F.
      Exploring the relationship between mental health stigma, knowledge and provision of pharmacy services for consumers with schizophrenia.
      As mentioned in the previous paragraph, there is an array of reasons why individuals from minority communities may avoid seeking mental health care. To address these issues, researchers have proposed various solutions, including providing cultural competency training to health care providers, patient education, expanding the number of mental health care providers and research participants from minority communities, and incorporating the cultural formulation interview (CFI) into counseling sessions. The APA’s cultural issues subgroup has tried to manage cultural competence through the formation of the CFI to assess how cultural behaviors influence the views of an individual on their mental health to enhance the validity of diagnostic assessment.
      • Lewis-fernández R.
      • Aggarwal N.K.
      Culture and psychiatric diagnosis.
      Because there is a current shortage of psychiatrists, it is imperative for pharmacists and other health care providers to help fill the gap in addressing the mental health concerns of their patients. The advantages and disadvantages of these solutions will be discussed further in this article. See Table 1 for studies that assessed solutions.
      Table 1Literature of interventions in cultural competency
      StudyObjectiveEvaluationConclusions
      Bhui et al.
      • Bhui K.
      • Warfa N.
      • Edonya P.
      • Mckenzie K.
      • Bhugra D.
      Cultural competence in mental health care: a review of model evaluations.
      Assess if cultural competency training improves quality of mental health care in racial and ethnic minority communities.Systematic review of evaluated models of professional education or service delivery.Limited evidence on best practices to provide effective cultural competence training owing to lack of evaluation of impact on outcomes. The most common methods used to teach cultural competence include lectures, case study discussions, role play, and video materials.
      Poirier et al.
      • Poirier T.I.
      • Butler L.M.
      • Devraj R.
      • Gupchup G.V.
      • Santanello C.
      • Lynch J.C.
      A cultural competency course for pharmacy students.
      Develop a course to teach cultural competency skills and increase awareness of personal biases.Precourse and postcourse score on the IAPCC-R.

      Portfolio responses with respect to cultural competency.

      SET.
      Portfolio responses suggested enhanced cultural competency after completing the course. However, IAPCC-R scores showed that students did not achieve proficiency. The SET responses found that students believed that the course improved self-awareness of biases and improved their cultural responses.
      Mills et al.
      • Mills S.
      • Wolitzky-taylor K.
      • Xiao A.Q.
      • et al.
      Training on the DSM-5 cultural formulation interview improves cultural competence in general psychiatry residents: a multi-site study.
      Evaluate if a 1-hour session on the CFI improves cultural competence of general psychiatry residents.Preintervention and postintervention questionnaire.

      Linear regression to assess if previous cultural experience predicts postintervention scores.
      The 1-hour training course did improve residents’ cultural competency scores.
      Abbreviations used: IAPCC-R, Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals (Revised); SET, student evaluation of teaching; CFI, cultural formulation interview.

      Literature summary of barriers and proposed solutions

       Didactic education

      Education for cultural competency begins when health care providers are students in their respective health professional schools. Most curricula for health professional schools now require some component of cultural competency training.
      • Bhui K.
      • Warfa N.
      • Edonya P.
      • Mckenzie K.
      • Bhugra D.
      Cultural competence in mental health care: a review of model evaluations.
      Although pharmacy and other professional programs recognize the importance of this training to address feelings of disrespect and distrust from minority communities, many struggle with its implementation.
      • Poirier T.I.
      • Butler L.M.
      • Devraj R.
      • Gupchup G.V.
      • Santanello C.
      • Lynch J.C.
      A cultural competency course for pharmacy students.
      Programs are discovering difficulties in developing appropriate class activities to create meaningful training that fits into the current curriculum.
      • Mian A.I.
      • Al-Al-Mateen C.S.
      • Cerda G.
      Training child and adolescent psychiatrists to be culturally competent.
      ,
      • Poirier T.I.
      • Butler L.M.
      • Devraj R.
      • Gupchup G.V.
      • Santanello C.
      • Lynch J.C.
      A cultural competency course for pharmacy students.
      In addition to identifying appropriate ways to incorporate training into the lessons, programs will have to learn how to make students and providers want to learn about other cultures to prevent disruption and acrimonious feelings toward patients of different cultures.
      • Bhui K.
      • Warfa N.
      • Edonya P.
      • Mckenzie K.
      • Bhugra D.
      Cultural competence in mental health care: a review of model evaluations.
      ,
      • Mian A.I.
      • Al-Al-Mateen C.S.
      • Cerda G.
      Training child and adolescent psychiatrists to be culturally competent.
      ,
      • Poirier T.I.
      • Butler L.M.
      • Devraj R.
      • Gupchup G.V.
      • Santanello C.
      • Lynch J.C.
      A cultural competency course for pharmacy students.
      A curriculum that is designed to create a safe learning environment for all students, have clear outcomes, center on the diversity of patients and human experiences, bring light to current biases and prejudices, integrate throughout the entire curricula, incorporate nonclassroom experiences, and require compulsory faculty training has been shown to have a positive impact on incorporating cultural competency as identified by a study performed in pharmacy education.
      • Poirier T.I.
      • Butler L.M.
      • Devraj R.
      • Gupchup G.V.
      • Santanello C.
      • Lynch J.C.
      A cultural competency course for pharmacy students.
      Through this training, current and future providers may increase their acceptance of diverse populations, allowing patients to feel more interpersonal comfort to engage in candid discussions of their problems.
      • Bhui K.
      • Warfa N.
      • Edonya P.
      • Mckenzie K.
      • Bhugra D.
      Cultural competence in mental health care: a review of model evaluations.
      Patients with providers who are culturally aware are more likely to continue seeking mental health care.
      • Trinh N.T.
      • Bernard-negron R.
      • Ahmed I.I.
      Mental health issues in racial and ethnic minority elderly.
      Programs should frame cultural competency training as a way for each profession to reduce health disparities and improve health outcomes, a common goal of pharmacists and other health professionals alike.
      • Poirier T.I.
      • Butler L.M.
      • Devraj R.
      • Gupchup G.V.
      • Santanello C.
      • Lynch J.C.
      A cultural competency course for pharmacy students.
      For instance, a pharmacy curriculum could highlight how a pharmacist with cultural competency training may be able to identify cultural perspectives on why patients are hesitant to use psychotropic medicines, appropriately build a rapport, and aid in dispelling any misperceptions. The belief is that the training will be carried forward to patient care.

       Pharmacy practice

      The CFI is a strategy that the APA’s cultural issues subgroup has used to improve cultural competence.
      • Lewis-fernández R.
      • Aggarwal N.K.
      Culture and psychiatric diagnosis.
      The CFI was introduced in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition); it is a standardized questionnaire to help reduce biases and is to be used at the beginning of the first counseling session.
      • Lewis-fernández R.
      • Aggarwal N.K.
      Culture and psychiatric diagnosis.
      The CFI is used to apply cultural–contextual factors to the diagnosis and treatment of mental illness and enhance the diagnostic assessment’s validity,
      • Lewis-fernández R.
      • Aggarwal N.K.
      Culture and psychiatric diagnosis.
      although it has been shown that patients may develop negative attitudes or emotions concerning their mental health and that they may find the questions to be ambiguous.
      • Aggarwal N.K.
      • Nicasio A.V.
      • Desilva R.
      • Boiler M.
      • Lewis-fernández R.
      Barriers to implementing the DSM-5 cultural formulation interview: a qualitative study.
      In addition to the patient-specific barriers of the CFI, providers may find that it is not always relevant to counseling sessions, the questions may seem repetitive, it is not useful for patients with severe illness, and it requires too much time to complete and thus may lead to providers avoiding its use.
      • Aggarwal N.K.
      • Nicasio A.V.
      • Desilva R.
      • Boiler M.
      • Lewis-fernández R.
      Barriers to implementing the DSM-5 cultural formulation interview: a qualitative study.
      The use of the CFI may lead to improved cultural competence of providers because they can learn and understand different cultures.
      • Mills S.
      • Wolitzky-taylor K.
      • Xiao A.Q.
      • et al.
      Training on the DSM-5 cultural formulation interview improves cultural competence in general psychiatry residents: a multi-site study.
      In fact, a study of a residency program that adapted the didactic lessons of the CFI to assess its effectiveness in improving cultural competency found a modest improvement in scores, even in residents with previous cultural training.
      • Mills S.
      • Wolitzky-taylor K.
      • Xiao A.Q.
      • et al.
      Training on the DSM-5 cultural formulation interview improves cultural competence in general psychiatry residents: a multi-site study.
      Currently, there is a lack of literature on the use of the CFI by pharmacists. Despite this, it may be beneficial to evaluate how a similar tool could improve communication strategies in pharmacists, considering that their responsibilities rely heavily on communicating with, and educating, patients. It is important to stress that the questionnaire focuses on how culture affects individual patients rather than assuming a cultural group’s views on the basis of a few representatives.
      • Mills S.
      • Wolitzky-taylor K.
      • Xiao A.Q.
      • et al.
      Training on the DSM-5 cultural formulation interview improves cultural competence in general psychiatry residents: a multi-site study.
      With the new communication strategies learned from the CFI, pharmacists may be able to better tailor patient education. This is especially important during the COVID-19 pandemic because providers should seek to maintain similar levels of service, flexibility in providing care, and relationships with patients from minority communities to respond to worsening mental health.
      • Smith K.
      • Bhui K.
      • Cipriani A.
      COVID-19, mental health and ethnic minorities.

       Patient education

      In addition to providing training to providers on cultural competency, patients must be educated on mental health care services. The primary barrier to providing education is reaching patients because many individuals from minority communities believe that problems should not be discussed outside of the family or mistrust the health care field.
      • Trinh N.T.
      • Bernard-negron R.
      • Ahmed I.I.
      Mental health issues in racial and ethnic minority elderly.
      In addition, providers have to combat the stigma of mental health within minority communities and recognize symptoms of mental health disorders that present differently than the norm.
      • Gary F.A.
      Stigma: barrier to mental health care among ethnic minorities.
      For example, black people are more likely to present as irritable or angry than present the commonly associated hopelessness and sadness of depression, whereas some American Indian languages lack the words to describe depression or anxiety.
      • Johnson J.L.
      • Cameron M.C.
      Barriers to providing effective mental health services to American Indians.
      ,
      • Stewart S.M.
      • Simmons A.
      • Habibpour E.
      Treatment of culturally diverse children and adolescents with depression.
      Learning how to discuss mental health issues with patients from minority communities may prove to be challenging to overcome for nonpsychiatric providers because they would need adequate training to feel equipped to communicate on mental health concerns. In addition, there would be a need to build workflows or integrated practices that allow for enough time and access to address mental health if it is not the patient’s primary concern.
      Pharmacists are the most easily accessible providers in the health care community. They can play an essential role in educating patients on mental health topics such as common and unique symptoms to help individuals from minority communities self-identify mental health concerns.
      • Rubio-valera M.
      • Chen T.F.
      • O’reilly C.L.
      New roles for pharmacists in community mental health care: a narrative review.
      Education on mental health and its treatment options can also increase interest in treatment with medication.
      • Stewart S.M.
      • Simmons A.
      • Habibpour E.
      Treatment of culturally diverse children and adolescents with depression.
      ,
      • Gary F.A.
      Stigma: barrier to mental health care among ethnic minorities.
      Through medication education, a pharmacist can dispel a common misconception in patients from minority communities that antidepressants are addictive and ineffective by providing information on when treatment response occurs and on potential adverse effects, as well as other information that may help reduce the stigma of psychotropic medications.
      • Stewart S.M.
      • Simmons A.
      • Habibpour E.
      Treatment of culturally diverse children and adolescents with depression.
      ,
      • Gary F.A.
      Stigma: barrier to mental health care among ethnic minorities.
      The information provided should help normalize mental illness and stress the importance of seeking treatment and its benefits.
      • Gary F.A.
      Stigma: barrier to mental health care among ethnic minorities.
      Through education, patients may increase their health literacy to understand their options and empower themselves to make the best decision.
      • Trinh N.T.
      • Bernard-negron R.
      • Ahmed I.I.
      Mental health issues in racial and ethnic minority elderly.
      ,
      • Stewart S.M.
      • Simmons A.
      • Habibpour E.
      Treatment of culturally diverse children and adolescents with depression.
      One initiative found that providing culturally tailored follow-up for patients from minority communities increased health literacy compared with regular informative texts or no follow-up at all.
      • Trinh N.T.
      • Bernard-negron R.
      • Ahmed I.I.
      Mental health issues in racial and ethnic minority elderly.
      A pharmacist could achieve this tailored approach by presenting information on the ways to reduce medication costs in patients from low-income minority communities or providing language-specific services (e.g., medication guides in a patient’s primary language).
      • Smith K.
      • Bhui K.
      • Cipriani A.
      COVID-19, mental health and ethnic minorities.

       Research

      Finally, minority representation in research as well as the number of mental health providers from minority communities need to be increased. Current mental health assessments are not validated in minority populations, making them inadequate to diagnose and assess mental illnesses in these populations.
      • Johnson J.L.
      • Cameron M.C.
      Barriers to providing effective mental health services to American Indians.
      ,
      • Gary F.A.
      Stigma: barrier to mental health care among ethnic minorities.
      There is also sparse evidence to show that psychotherapy and pharmacological agents are as effective in patients from minority communities.
      • Sue S.
      In search of cultural competence in psychotherapy and counseling.
      Despite the need for an increase of these populations in research, it is often difficult to recruit them owing to their mistrust of the health care community and the stigma surrounding mental health. Moreover, there may be difficulty in increasing the number of mental health care providers from minority communities owing to costs and other access barriers in higher education, and, as aforementioned, possible cultural biases against mental health in general.
      An increase in minority participation in research will allow for the development of culturally sensitive interventions and provide a look at which treatment options may best work for individuals from minority communities or if they benefit differently from the current recommendations.
      • Mian A.I.
      • Al-Al-Mateen C.S.
      • Cerda G.
      Training child and adolescent psychiatrists to be culturally competent.
      Because pharmacists have well-established relationships with their patients and providers in the health care system, they could work with researchers to provide information to patients on research opportunities and play a vital role in identifying potential participants for future studies. Mental health care providers from minority communities may reduce the linguistic mismatch between patients and providers because those with similar cultural backgrounds may improve the validity of a provider’s assessment and assist in building a rapport with patients.
      • Sue S.
      In search of cultural competence in psychotherapy and counseling.
      A few studies have found that when there is an ethnic match between patient and provider, there are fewer premature terminations and better outcomes, and patients do better during sessions.
      • Sue S.
      In search of cultural competence in psychotherapy and counseling.

      Conclusion

      The lack of cultural competency training among providers is believed to be 1 of the reasons for the underuse of mental health resources in underrepresented minority communities. Additional factors include stigma in minority populations and lack of understanding of the importance of mental health care. As the United States continues to diversify, racial disparities in health care increase, and there is a shortage of psychiatrists, it will be paramount for other health care providers, including pharmacists, to learn how to adequately provide care to culturally diverse patients with mental health concerns. Current literature on how best to train and incorporate cultural competence into care is sparse, and potential solutions come with barriers that have yet to be resolved. Thus, more research is needed to develop culturally competent guidelines for treating underrepresented patients from minority communities with mental illnesses.

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      Biography

      Alana N. Rice, PharmD, PGY1 Pharmacy Resident, Michael E DeBakery Veteran Affairs Medical Center. Houston, TX

      Biography

      Suzanne C. Harris, PharmD, BCPP, Assistant Professor, Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy; and Clinical Pharmacist Practitioner, Department of Pharmacy, UNC Medical Center, University of North Carolina at Chapel Hill, Chapel Hill, NC