Racial Differences in Preferences and Behaviors in Prescriber-Patient Communication Among Veterans with Serious Mental Illness

Purpose: Research on racial differences in clinician-patient communication has revealed mixed findings. Johnson, Roter, Powe, and Cooper (2004) found that physicians were more verbally dominant and less patient-centered in their communication with African American patients compared to White patients while Hausmann et al. (2011) found only minimal differences in visit structure and content. In interviews with African American patients about what it means to share in the decision making process Peek et al. (2008) found that African American patients focused on the importance of information sharing and feeling heard by prescribers, rather than participating in decision making about their health care. The objective of this research was to understand if racial differences existed among Veterans with serious mental illness’ satisfaction with prescribers and mental health appointments, rating of therapeutic alliance, preferences for different aspects of shared decision making, and perceptions of prescriber-patient communication.

Methods: Participants were Veterans who had psychotic disorders and were being treated in one of two Veterans Affairs outpatient mental health clinics. Participants completed a patient satisfaction questionnaire, patient self-report questionnaire of communication and decision making preferences with prescribers, BASIS-24 (self report of mental health symptoms and functioning),  and STAR (therapeutic relationship assessment). For each participant one visit with a psychiatrist or nurse practitioner was audio taped and analyzed using the Roter Interaction Analysis System (RIAS) to characterize patterns of communication.

Results: There were no racial differences in patient satisfaction with the prescriber visit between African American Veterans (n=83) and White Veterans (n=81). African American Veterans with SMI were less likely to prefer relying on their prescriber’s knowledge about mental illness (p=.039), less likely to prefer to let the prescriber make mental health care decisions without their input (p=.036), and more likely to perceive that their prescribers involved them in decision-making around their mental health treatment (p=.024). RIAS analyses of patient-prescriber communication found that African American Veterans had shorter appointments (18.6 minutes, SD=10.8) compared to White Veterans (22.4 minutes, SD=11.9; p=.034). African American Veterans were also less engaged during appointments (p=.023) and talked less (p=.009). Despite these self-reports, the RIAS did not reveal any differences in prescriber communication patterns and behaviors related to patient race.

Implications: While African American veterans reported preferences for engaging in participatory decision making and seeking their own information, they may not have the skill set or knowledge to do so. African American patients may benefit from patient self-advocacy information that educates patients on how to prepare for appointments, what questions to ask, what shared decision making entails, and how to work toward their ideal relationships with their clinician. African American patients’ preference for not relying on prescribers for knowledge about mental illness may be indicative of cultural mistrust in mental health care and underline the need for attention to development of therapeutic alliance. However, these findings also suggest that regardless of patient behaviors, prescribers can minimize health disparities by maintaining appropriate levels of engagement and communication with all patients.