Does Ethnicity Affect Service Engagement or Clinician Perceptions of Early Psychosis Patients?

An extensive literature has described the effects of ethnicity upon service use, access to health care, treatment, and outcomes. Most of this literature focuses on the UK and US populations and historic ethnic inequality, while the Canadian environment is perceived as generally benign and non-discriminatory.

The First Episode Psychosis Program (FEPP) at the Jewish General Hospital in Montreal, Canada comprises close follow-up and specialized services for patients and their families over a 2-year period by a psychiatrist and a case manager. The program’s patient population is ethnically diverse (in our sample from 2008–2012, 50% belonged to visible minorities, and half of those were black). All clinicians are white.

My colleagues and I hypothesized that visible minority (VM) patients with psychosis may represent a population that is particularly vulnerable to suboptimal health care due to the severe symptoms they experience and the baseline discrimination they face in Canadian society. Further, patients with psychosis have been reported to have high rates of nonadherence to medical treatment and absence from scheduled appointments, presenting an even greater challenge to the delivery of appropriate care.

In our study, we looked both at the retrospective chart records of 168 patients referred to the program and at questionnaires completed by the FEPP case managers (CMs) about their perceptions of each patient’s adherence to appointments and medication, insight, family involvement, etc. This allowed us to triangulate real and perceived adherence and to find out if the clinicians’ perception of patients differs based on the patients’ ethnicity. We used both quantitative and qualitative data to get a rounded picture.

In concordance with studies from other countries, we found that black patients have significantly lower attendance at follow-up appointments than white patients, adjusted for age and sex. When we looked at the CMs’ perceptions of patients’ service use, however, a peculiar pattern emerged. With VM patients, CMs were over 90% accurate in recalling which patients had good follow-up, but CMs were much less (72%) accurate when recalling which white patients had good attendance. This difference possibly reflects a priori lower expectations among clinicians for VM patients. The CMs did not accurately recall which patients had poor follow-up, regardless of patients’ ethnicity (50%, or equal to chance).

On the questionnaires, no significant differences were found between white and visible minority groups in CMs’ perceptions of adherence to appointments, adherence to medication, insight, or family involvement.

These results may be clinically helpful to those working with vulnerable populations with early psychosis. VM youth may be dropping out of psychiatric services very early in the treatment process, perhaps even before entering the clinic doors. First-episode psychosis clinical teams should focus resources on the earliest contacts with VM patients to help them access psychiatric services in a timely manner. Clinical programs should be adapted and receptive to linguistically and culturally diverse patients and their families. Finally, clinicians should be aware of their preconceived expectations of VM patients because clinician attitudes and beliefs may influence perception of adherence and other outcomes. We believe that the double subject set (patients and CMs) and mixed-method design of this study are original and useful approaches to look at complex issues of bias and service engagement.

Financial disclosure:Dr Nikolitch has no relevant personal financial relationships to report.