Mental Health Equity Begins With Resident Recruitment: The Impact of Recruiting a Diverse Psychiatric Workforce

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AMERICAN ASSOCIATION FOR PSYCHIATRIC ADMINISTRATION AND LEADERSHIP

With residency recruitment season ending, it is time to examine how resident selection has far-reaching impacts on patient care in all fields, especially in psychiatry. Being a part of the selection process, whether as a faculty member or a current resident, is not only a privilege as a psychiatrist, but a major responsibility. Social determinants of health, defined as the conditions in which individuals are born, grow, work, and age,¹ are leading drivers in the development of mental and substance use disorders.² There is a need for psychiatrists to possess an in-depth understanding of these factors, including income inequality, discrimination, adverse childhood experiences, food insecurity, and other environmental factors. To meet this need, program directors must recruit applicants with diverse backgrounds and experiences during the residency selection process.

According to the American Psychiatric Association (APA), racial/ethnic, gender, and sexual minorities are at increased risk for poor mental health outcomes.³ These differences in morbidity and mortality are the result of biases in diagnoses, cultural differences in symptom presentation, and limited access to mental health treatment. These disparities have substantial implications and extend beyond mental health; they impact the education system, social services, and the criminal justice system.⁴

Individuals who identify as American Indian/Alaska Native (AI/AN) make up approximately 2% of the United States population.⁵ However individuals in this population report the highest number of major depressive episodes, and a higher incidence of posttraumatic stress disorder, substance use disorders, and suicidal behaviors when compared with other racial and ethnic groups.⁶ Among AI/AN youth, suicide was the leading cause of death in girls between the ages of 10 and 14.⁷ In AI/AN adults, the suicide rate was 20% higher when compared with non-Hispanic White adults.⁸ These disparities are impacted by various socioeconomic differences including lower educational achievement and lower income of individuals in the AI/AN community.⁶

African Americans have similar rates of mental illness compared with the general population, but only a third of these individuals receive mental health care. Those who do receive care are less likely to receive quality and culturally competent care.^9,10 These disparities have widespread impacts and begin during youth. Racial minority youth who have behavioral health issues are more likely than White youth to be referred to the criminal justice system.¹¹ Research indicates that when diagnosed with schizophrenia or bipolar disorder, African Americans are more likely to be incarcerated compared with individuals from other races.¹²

The APA cautions that a lack of understanding by health care providers may contribute to underdiagnosis or misdiagnosis of mental illnesses in those from racially and ethnically diverse populations. Suicide was the leading cause of death for Asian/Pacific Islanders aged 15 to 24 in 2019; however, when compared with non-Hispanic White individuals, Asian Americans were 60% less likely to have received mental health treatment.¹³ Perceived lack of cultural competence among mental health providers impacts this disparity. Young Asian American adults reported that there is an inadequate number of mental health professionals who possess the cultural and linguistic competence required to provide quality care to members of their community.¹⁴ Hispanic/Latinx patients share similar experiences, with up to 44% of these patients reporting that communication problems and cultural differences play a role in poor health outcomes within their community.¹⁵

Individuals who identify as lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) are up to 2.5 times more likely to report mental health disorders including anxiety and depression, compared with heterosexual individuals.¹⁶ LGBTQ youth are at increased risk for poor mental health outcomes. According to Centers for Disease Control and Prevention’s (CDC) Youth Risk Behavior Survey, suicidal thoughts and behaviors in LGBTQ youth increased from 2011 to 2021, with more than 20% of surveyed students reporting a suicide attempt.¹⁷ Historically, LGBTQ patients have avoided mental health care and routine medical treatment due to stigma and discrimination that they face in society. LGBTQ patients are also more likely to report that their health care provider’s knowledge and desire to adapt to their needs is inadequate, which in turn impacts their willingness to seek treatment.¹⁸

Diversity and cultural competence amongst psychiatrists have been shown to improve patient care outcomes. Patients who perceive discrimination from their mental health providers are at increased risk of worsening mental health.¹⁹ For this reason, a diverse psychiatric workforce is essential for addressing mental health equity in minority populations. Mental health equity is defined by the CDC as the state in which everyone has a fair and just opportunity to reach their highest level of mental health and emotional well-being.²⁰ An example of how mental health equity can be addressed by having a diverse provider population was seen in a retrospective cross-sectional study assessing patient perceptions of provider cultural competency. In the study, adults diagnosed with depression, patients who identified as female, and those with low socioeconomic status, felt more connected with providers who expressed an interest in their culture and background. This desire for culturally competent care was more pronounced in patients who identified as Black, African American, American Indian, Alaskan Native, and those who identified their ethnicity as Hispanic.²¹

Psychiatry residency programs are at the forefront of addressing health care disparities. This begins with the resident selection process. Program directors must review their mission statements to ensure that their mission aligns with the mental health needs of their community, while also making concerted efforts to address mental health inequities faced by patients throughout the country. To diversify the psychiatric workforce, residency programs can implement a holistic review process when selecting applicants to interview. According to the Association of American Medical Colleges (AAMC), holistic review is a flexible, individualized, mission aligned process that takes into consideration an applicant’s experiences, attributes, and academic metrics to gauge the value that an applicant might contribute to a program.²² When institutions utilize a mission driven, holistic review process, rather than using academic metrics alone, there is a significantly higher than expected percent of female applicants, applicants who are underrepresented in medicine, first-generation applicants, and applicants who self-identify as disadvantaged.²³ To recruit applicants from diverse backgrounds, residency program directors must also look at the demographics of the faculty within their institution and assess whether a significant number of these individuals identify as racial/ethnic, gender, or sexual minorities. Representation matters at every level of medical education. In a study investigating factors that influenced the residency rank list of applicants who were underrepresented in medicine, the presence of racial/ethnic or gender diversity of current faculty was viewed as most important.²⁴

It must be noted that diversity encompasses physical, social, and psychological differences, and is not limited to an applicant’s race, ethnicity, religion, socioeconomic status, education, age, sexual orientation, or gender identity, although these are all important factors to consider in the residency selection process.²⁵ Psychiatry residency directors can refer to the AAMC’s Holistic Review Framework which includes a model for selection known as the Experiences-Attributes-Competencies-Metrics (E-A-C-M model) for understanding various dimensions of diversity.²² Within the “Experiences” component of the model, an applicant’s life experiences, community service, and experience with diverse populations are highlighted. In the “Attributes” component of the model, programs are encouraged to consider an applicant’s cultural competency and proficiency in more than 1 language. The “Competencies” component of the E-A-C-M model is also significant because it considers how an applicant might apply their experiences and attributes to patient care. In the “Metrics” component of the E-A-C-M model, scholarly work and academic performance is also highlighted; however, it is not viewed as the most important factor in the applicant selection process, allowing for well-rounded residents.

In addition to the AAMC’s guidelines for holistic review, program directors should consider recruitment from applicants affiliated with organizations that highlight and celebrate diversity in health care. This includes recruiting applicants involved in the Student National Medical Association, the Latino Medical Student Association, and the Medical Student Pride Alliance amongst others. In recognizing the importance of cultural competency amongst future psychiatrists, programs should also recruit from historically black colleges and universities (HBCUs), which provide access to a large pool of diverse applicants who are often overlooked in the selection process. Civic engagement plays an important role in the mission of HBCUs and students from these institutions are trained in academic settings that prioritize health care disparity reduction through community engagement with minority, low-income, and underserved patient populations.²⁶

There is still much work to be done within the field of psychiatry. We can begin this work by recruiting diverse psychiatrists who can recognize and appreciate how mental health disparities impact their patients on an individual and societal level. Aspiring psychiatrists must be up to the task of forging a path forward in the fight to eliminate mental health disparities by way of community, societal, and policy-level interventions. Mental health equity is not possible without a diverse workforce, and as Maya Angelou once stated, “In diversity there is beauty and there is strength.”

Dr Curry is PGY-3 psychiatry resident physician at the Sandra and Leon Levine Psychiatry Residency Program, Atrium Health Wake Forest University School of Medicine. Dr Villanueva is clinical assistant professor department of Psychiatry and Behavioral Medicine at Wake Forest School of Medicine. He is also medical student clerkship director in psychiatry, associate psychiatry residency program director, and co-medical director of the Behavioral Health Advanced Practice Provider Fellowship Program at Atrium Health.

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