Mind the Gap: scaling-up access to culturally adapted mental health treatments for minority populations

The Mind the Gap (MTG) consortium aims to increase mental health literacy and access to evidence-based internet-delivered treatments for minority groups. Strategies include digital recruitment, psychoeducational resources, and culturally adapted treatment content. MTG is committed to inclusivity and scaling-up access to bridge the mental health gap for minority populations.

Background

Minority populations, including forced migrants, suffer from disproportionate levels of mental health problems, including post-traumatic stress disorder (PTSD), depression, and anxiety [1]. Despite the clear need for mental healthcare, minority groups experience lower rates of healthcare seeking and under utilization of mental healthcare [2]. Barriers to accessing mental healthcare in these populations include structural challenges such as language barriers, health literacy, and distance from needed care, as well as perceived barriers such as stigma and cultural norms [3].

One pathway to bridge this treatment gap and enhance access to mental healthcare is through Internet-delivered Cognitive Behavioral Treatments (I-CBT). Individuals can now access evidence-based therapy online through standardized text-based modules that contain interactive exercises tailored to their needs, as well as continuous therapist support from the privacy of their own homes. I-CBT is effective in treating a wide range of common mental health conditions such as depression, anxiety, PTSD, substance use disorders, and stress [4]. Furthermore, I-CBT has been successfully integrated into specialized psychiatric services in Sweden and other countries [5]. Thus, I-CBT appears to offer a revolutionary approach to mental healthcare, with the possibility of providing accessible, convenient, and effective interventions.

For minority populations, I-CBTs for common mental health conditions could offer significant benefits by increasing access to psychological treatment that is individualized and culturally adapted, serving to reduce barriers associated with seeking mental healthcare. This could be accomplished if online treatments are developed in collaboration with minority groups. In a recent systematic review of internet-based interventions, Spanhel et al. [3] identified a taxonomy of cultural adaptations, including illustrated characters/cases, activities, environments/burdens, and language considerations. Yet, I-CBT is primarily adopted by the majority population in society [3] and is currently underutilized by minority groups who could benefit from such interventions, such as migrant youth populations with severe distress [6].

In an effort to enhance equity in access to mental healthcare, the research consortium Mind the Gap (MTG; www.mindthegapstudies.com) was launched in 2020 at Karolinska Institutet, in Stockholm, Sweden. Language-incongruent encounters with the healthcare system increase the risk of inadequate communications, misdiagnosis, mistrust of the system, and possible further worsening of symptoms [7, 8]. This, coupled with planned governmental reduction in language interpretation services, further increases the gap in mental health equity in Sweden. Therefore, the overarching goal of MTG is to proactively expand access to mental healthcare to individuals who typically experience barriers in accessing evidence-based psychological treatment, such as those hindered by language barriers. The aim of MTG will be achieved by using a comprehensive research framework including several methodological considerations.

Raising awareness of mental health

A key research track within MTG is devoted to mental health literacy, with an emphasis on the pedagogical approach and cultural adaptations in the form of adverts, psychoeducation, and treatment manuals. We will develop and utilize culturally adapted digital advertisements and brief online social media posts in different languages, to increase awareness on common mental health issues and facilitate treatment-seeking, among affected individuals. Current work within MTG also includes production of psychoeducational films on different diagnoses with experts in the field, which will be launched in conjunction with the dissemination of the different I-CBT programs. To understand the effectiveness and suitability of these approaches, we aim to systematically evaluate the diverse content (i.e., the advertisements and treatment material) with support from stakeholders and end-users, who represent the minority groups. For example, in a recent social media campaign featuring an expert on PTSD, we showcased a psychoeducation video alongside a case example to provide factual information of the diagnosis coupled with a patient’s narrative about symptoms and experience with CBT. Through this campaign, we aimed to encourage participation in an I-CBT treatment study specifically designed for migrants with PTSD in Sweden. Consequently, we received over 100 applicants from the target population, signing- up for I-CBT treatment between February to April 2024, possibly reflecting a significant clinical need and the potential efficacy of educational and tailored campaigns. When participants self-registered on the MTG webpage, we also gathered data on other relevant aspects including participant perspectives, language preferences, and inclusiveness of campaigns.

Using a broad approach to target populations in need of treatment

While it can be pivotal to prioritize particular groups in need, we recommend starting with a broader approach, targeting [1] research-informed and highly prevalent mental health conditions among minority populations, and [2] using I-CBT language adaptations for the largest minority languages spoken in Sweden, for example, easy-to-read Swedish, English, or Arabic. Using such a wide approach can result in a low threshold to treatment recruitment for participants from several minority populations, while at the same time underlining the importance of systematically analyzing post-treatment outreach data to identify potential groups that have not been reached. Inclusive research that engages heterogenous populations also allows for more successful implementation in the real-world setting.

Culturally adapted evidence-based treatments

While several treatment barriers may exist among minority groups, we emphasize that the lack of inclusive and language-specific treatment options might constitute a structural obstacle for minority populations. A recent meta-analysis shows promising results that culturally adapted evidence-based interventions are effective across cultures [9], although there is a need to study and identify the components of cultural adaptations for different groups and treatment interventions [10]. The MTG clinical track is focused on cultural and language adaptation, evaluation, and large-scale dissemination of I-CBT for common mental health disorders in minority groups. Examples of ongoing and planned studies within the consortium include I-CBT for excessive worry, PTSD, insomnia, risky alcohol consumption, common mental health disorders among sexual minority groups, and telephone-based support for problem gambling, in easy Swedish, English, Arabic, and other key minority languages (see for instance Clinical trials NCT06193161 https://clinicaltrials.gov/study/NCT06193161 and Centre for Open Science https://osf.io/g7bkv/). We strive to evaluate the treatment interventions in a systematic and stepwise fashion, beginning with feasibility trials, followed by randomized controlled trials, and subsequently effectiveness and implementation studies.

From a clinical standpoint, we emphasize that I-CBT interventions are built on a set of evidence-based principles, assumed to be universal in how mental health conditions are best treated. Therefore, as a rule of thumb, treatment rationales, components and interventions should be close to original treatment protocols, ensuring an evidence-based approach. Cultural adaptations may instead consider language and format, such as condensing treatment texts, emphasizing core treatment principles, and the inclusion of patient examples from diverse cultural backgrounds [3]. We are systematically evaluating cultural adaptations in I-CBT programs by collecting participant feedback on treatment material. This includes assessing how well patient examples and clinical presentations resonate with their cultural background. Regarding additional treatment outcomes, we recommend they are based on co-creation processes with users who have lived experience. These outcomes could include adherence, mental health knowledge, perceived barriers to treatment-seeking, healthcare utilization, or prior experiences of culturally based attitudes from healthcare representatives. Furthermore, it is important to clearly explain the rationale for I-CBT. This could be achieved, for example, with a telephone-based clinical assessment interview and by providing clear information on the treatment process to improve treatment adherence.

Implementation and dissemination

The ultimate goal is for I-CBT to be implemented as part of routine healthcare. If culturally adapted, I-CBT could be effectively delivered in an unguided format (without the support of a therapist), which may facilitate an expedited healthcare process in terms of reducing the need for language expertise and enhancing cost-effectiveness. Therefore, the MTG clinical track aims to identify the need for language specification, level of cultural adaptations, and therapist involvement, in order for I-CBT to be easily scalable. In parallel, we also recognize the importance of continued education for clinicians in the area of cultural psychiatry to better meet the needs of the patients accessing care. Therefore, the implementation process will factor in continuing education within the MTG consortium. In the long term, we further plan to investigate whether MTG increases access to, and use of, digital interventions over time, and its impact on the health equity of minority populations using linked healthcare registers.

Implications

In summary, the MTG research consortium aims to establish a knowledge base to increase accessibility to mental healthcare and culturally adapt I-CBT for minority populations. MTG acts as a catalyst for achieving mental health equity by diminishing treatment barriers and prioritizing person-centered care, achieved through systematic and ongoing evaluation in collaboration with minority groups. A global call for collaborative efforts is extended with regard to MTG, recognizing that similar mental health disparities persist among minority groups across various nations.