OPAL 2 Exploratory Project 1

Improving Assessment of Psychosis and Engagement in Treatment of BIPOC Individuals

Black, Indigenous and People of Color (BIPOC) individuals are more likely to be misdiagnosed with schizophrenia and other psychotic disorders and to disengage from mental health services than non-Latinx White patients. In addition to systemic factors (e.g., lack of insurance), other contributors to disparities include deficits in patient-provider communication (e.g., less patient participation), provider inattention to culture (e.g., cultural illness explanations), and social determinants of health (e.g., racism impeding access to care). Hence, BIPOC patients can become dissatisfied, ask fewer questions, withhold information, and discontinue treatment. However, positive communication is linked to negotiating consensus around patients’ views of illness and treatment with greater engagement in services. This project aims to improve provider communication with BIPOC individuals during outpatient assessment, treatment discussions, care initiation, and maintenance for schizophrenia and other psychotic disorders by adapting a 3-session intervention, Cultural Formulation Interview-Engagement Aid (CFI-EA), for individuals with psychosis (CFI-EA/P). This intervention is based on the DSM-5 Cultural Formulation Interview (CFI), a 16-item, semi-structured interview to personalize cultural assessment through culturally sensitive provider communication behaviors (e.g., open-ended questions; activation statements). The CFI-EA/P includes standardized assessments of mood symptoms and social determinants of health to reduce misdiagnosing schizophrenia and to focus provider attention on socio-structural factors in engagement. With iterative stakeholder input (patients, clinicians, care coordinators, administrators) and mixed (qualitative-quantitative) methods guided by the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME), we propose to adapt, manualize, and pilot the CFI-EA/P in a large outpatient mental health system with a 90% BIPOC patient population. The study design completes Stage I of the National Institutes of Health Stage Model of Intervention Development, including: iterative adaptation of the CFI-EA/P manual, training workshop, and fidelity instrument (Stage 1a); evaluation of the CFI-EA/P’s feasibility and acceptability for patients and clinicians (Stage 1b); and pilot testing service outcomes (treatment engagement, culturally competent communication, shared decision making, diagnostic concordance with research assessment) and patient outcomes (symptom improvements, quality of life, and psychosocial functioning) in a small randomized controlled trial to inform a future larger trial (Stage 1c). Consistent with the ALACRITY model, the CFI-EA/P would be available for immediate use in community-based outpatient clinics to address disparities in the care of BIPOC individuals accessing care for psychotic disorders. Study findings will guide further research on the CFI-EA/P.

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