The Right Question Project-Mental Health: An Intervention to Increase Engagement and Retention in Mental Health Care

The intervention is one of two Cambridge Health Alliance (CHA) projects from the University
of Puerto Rico-Cambridge Health Alliance Research Center of Excellence (UPR-CHA RCE). The
overall goal of the project is to evaluate an intervention that teaches patients a set of
skills needed to facilitate a more active patient role in the mental health encounter,
emphasizing the patient's decision-making process during mental health treatment. The
project also aims to support collaborative provider-patient relationships in order to
increase engagement and retention and, consequently, reduce service disparities. The
intervention has been pilot-tested in the Right Question Project-Mental Health I (RQP-MH I)
study (Alegría, 2008), conducted as part of the UPR-CHA EXPORT Center from September 2004
through February 2006.

The first aim of the current project is to conduct a multi-site randomized controlled trial
to test the Patient Activation and Self-Management (PASM) intervention, also called RQP-MH
II, in predominantly Latino mental health clinics. The investigators will assess the
intervention's impact on engagement and retention in mental health care. The second aim is
to explore the racial/ethnic differences in the effect of the RQP-MH II intervention for
Latinos as compared to non-Latino whites, as little is known about the impact of patient
race/ethnicity on the effectiveness of patient activation interventions. The fourth aim is
to explore the role of patient-provider communication and therapeutic alliance as mediators
of the relationship between patient activation and engagement and retention in care. It is
expected that increased patient-provider communication and a stronger therapeutic alliance
will result from increased participation in the decision-making process. These potential
changes in the process of care are expected to consequently increase patient engagement
(keeping scheduled appointments) and retention (reduction of premature unilateral
termination) in mental health care.

Data shows that patients may not readily state their concerns in their medical visits (Roter
et al., 1997; Korsch, Gozzi & Francis, 1968) and usually refrain from engaging in
information-seeking (Beisdecker & Beisdecker, 1990). Minority patients are even less likely
than their white counterparts to have a collaborative relationship with providers
(Cooper-Patrick et al., 1999). This is a problematic situation particularly for minority
patients, such as Latinos, who cherish maintaining a warm personal connection with their
providers (American Medical Association, 1994) and may worry that bringing up questions or
asking for explanations might jeopardize the relationship.

Minority patients may not be as informed about diagnosis, prognosis, and medication side
effects (Schaafsma, Raynor & de Jong-van den Berg, 2003) and consequently feel disappointed
that they do not receive needed information (Levinson et al., 1993). They may therefore be
less compliant with treatment (Kalichman et al., 1999), and more likely to drop out of care
(Takeuchi et al., 1992). Minority patients may have a less comprehensive understanding of
mental health care compared to White patients (Miranda and Cooper, 2004). As a result, they
are at a greater risk of assuming that the provider's decisions reflect their best interest
(Flynn et al., 2004). This is exemplary of Latinos who hold traditional role expectations
that oppose active involvement in the clinical encounter and prefer to delegate decisions
about their care to their providers (Levinson et al., 2005; Xu, Borders & Arif, 2003).

To contend with difficulties in communication, most interventions focus on provider training
(Post, Cegala & Miser, 2002), with less attention on teaching patients how to effectively
express their concerns and questions to their providers (Andersen & Sharpe, 1991; Roter,
1977). Yet results from assessments of self-management of chronic conditions (Hall, Roter &
Katz, 1988; Stewart et al., 1993) indicate that greater patient activation and
self-management in treatment can augment satisfaction with care (Blanchard et al., 1990),
improve the health care process (Rosenberg, Lussier & Beaudoin, 1997; Epstein et al., 1993),
ensure the receipt of guideline concordant treatments (Clever et al., 2006), and potentially
enhance health outcomes (Kaplan, Greenfield & Ware, 1989).

Most studies of patient activation and self-management in the field of mental health care
have not been conducted with minority populations of low literacy nor in a language other
than English. Most have not included mixed-methods (qualitative and quantitative) to
evaluate the effectiveness of the intervention, and have not obtained cost information that
can help evaluate whether changes in patient activation and self-management, or in treatment
engagement and retention, could potentially produce savings in treatment or health care
outcomes.

The proposed project is expected to fill this gap, assessing the effects of a patient
activation and self-management intervention using a mixed-methods approach, with three data
collection periods. The investigators hypothesize that patients participating in the patient
activation and self-management intervention will be significantly more likely to engage and
remain in mental health care, and will report significantly higher activation and
self-management scores as compared to control patients. Given the relationship of patient
participation and health outcomes, increasing Latino patient's participation in
decision-making a as mechanism to eliminate service disparities is the goal of the proposed
intervention.

Inclusion Criteria:

- between ages of 18 and 70 (patients above age 65 will be administered the Mini-Cog, a
cognitive impairment screener)

- speak English and/or Spanish

- currently receiving outpatient mental health care

Exclusion Criteria:

- suicidal ideation or attempt within the past four weeks

- lacks capacity to consent (adapted from Zayas, Cabassa, & Perez, 2005)

- only receiving services that are strictly case-management