Evaluating quality of psychiatric care for immigrants and people with a non-English language preference, a systematic scoping review

Abstract

Objective:

Immigrants or persons with non-English language preferences (NELP) face unique challenges in the mental healthcare system. This systematic review evaluates current literature for differences in psychiatric care delivery beyond access and utilization barriers for these two populations.

Methods:

The authors queried four databases: PubMed, PsycINFO, Web of Science, and CINAHL. Studies between August 1993 and August 2023 were included if study populations included immigrants to English-language countries or patients with NELP and a mental illness, had a relevant comparison group, and outcome measures focused on quality of psychiatric care delivery. Exclusion criteria comprised studies solely commenting on access or utilization, or without original data, single case reports, and commentaries.

Results:

The search identified 2860 studies. 17 studies were included in full text review (Cohen’s Kappa = 0.96). The authors found large variability in quality measures used in the studies. Outcome variables included involuntary treatment rates, symptom management, unmet needs, medication use, diagnosis, and medication monitoring. Immigrants were more likely to receive involuntary treatments in six of six included studies. There were insufficient numbers of studies focused on other outcome measures, limiting conclusions.

Conclusions:

Many included studies highlighted differences in care, especially in terms of involuntary hospitalization rate. The authors highlight variability in current outcome measures and deviation from established quality metrics. There is insufficient data to determine if the identified differences in care represents a care delivery gap. Additional studies utilizing standardized measures would assist in evaluating the quality of care received by immigrants and patients with NELP.

Introduction

Mental illness is substantially prevalent in the general population, with an estimated 59.3 million adults living with a mental illness in the United States (US) in 2022 and 970 million globally (1, 2). In addition to the significant impact on adults living with mental illness, this has a large impact on the healthcare system, with estimated 30 million adults receiving mental health treatment in 2022 (1). Non-medical factors, termed the social determinants of health, all influence health outcomes (3). These factors disproportionately affect persons with a non-English language preference (NELP) and immigrants (4, 5).

These groups face unique barriers to care. Within the US, people with a NELP must navigate an English-predominant healthcare system and rely on interpreters to convey their perspective to members of the healthcare system/team (6). In psychiatry, language discordance can be especially difficult to overcome, as miscommunications can disrupt the disclosure of stigmatizing information and lead to misdiagnosis (7). Despite representing a heterogenous group, immigrants may also have unique challenges, beyond language discordance, in traversing a new health system. Even individuals immigrating to and from English-predominant countries may face complexities in navigating a culturally distinct healthcare system. Immigrant populations often experience unique pre-migration and migration stressors and are tasked with developing a bicultural identity after immigration (8). These challenges are well-established in psychiatry, with the term “cultural concept of distress” being introduced in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (9). Specifically, the introduction of a cultural formulation for diagnosic clarity emphasizes how patterns in mental health can be informed by a person’s unique background and culture.

Quantifying differences in psychiatric care and improving mental healthcare equity for persons with NELP and for immigrants has been a growing area of focus globally. Compared to patients with an English language preference, patients with NELP have been shown to utilize less mental health services (4, 10, 11), have lower odds of receiving needed services (12), and have fewer mental health visits (13). Similar findings have been identified for patients who are immigrants (14, 15). A plethora of scientific literature across many nations documents the prevalence and incidence of a variety of mental health disorders in the child and adult immigrant population (16–23). Yet a recent systematic review found immigrants utilize fewer mental health resources than their native-born counterparts (5). Multiple qualitative research studies have evaluated provider and patient views of mental health stigma, etiology, diagnosis, and treatment (24–32)among both immigrants and persons with NELP. This is further augmented by editorial and commentary pieces advocating for collaborative care and management approaches for these populations (33–36). Yet despite substantial research on prevalence, mental health service utilization, patient-reported experience, and recommendations for improved communication, there is a comparative gap in the literature evaluating quality of care delivery for these populations in mental healthcare settings

Outside of mental healthcare settings, there is significant evidence both immigrants and patients who have a NELP experience care inequities. Within the surgical fields, patients with NELP were more likely to experience longer admissions and poorer post-surgical discharge compared to patients with an English preference (37). In emergency care settings, patients with NELP were more likely to be admitted and had higher rates of diagnostic testing compared to English-proficient patients (38). In primary care, adults with NELP were more likely to be overdue for preventative measures such as colorectal cancer screenings (39). Other studies report lower satisfaction with healthcare, an incomplete understanding of diagnoses, and subsequently lower rates of adherence to clinician recommendations among persons with NELP, compared to English-proficient patients (40–42).

Within psychiatry, quality of care for patients with NELP and immigrants remains less defined. One proposed reason is the unique challenges to quality measurement in psychiatry, ranging from limitations in infrastructure and policy to limited scientific evidence and training (43). Wheras the quality of care in other speciaties follow established, measureable, and numeric metrics, psychiatry quality has been difficult to characterize quantitatively (43). In 2016, a team of researchers developed the current landscape of quality measures for psychiatry, separating measures into eight domains: diagnostic assessment, evidence-based pharmacotherapy, patient centered care, coordination of care, access measures, utilization, patient safety, and outcome assessment (44). Common quality measures included screening and follow-up, medication monitoring and adherence, and patient experience, as well as access to mental health services and utilization of care. In 2022, the American Psychiatric Association released quality measures to improve standardization and lay the foundation for a national-level data infrastructure (45). These 28 measures broadly span screening and assessment tools, the management and monitoring of medications, documentation, and reduction in suicidality (46).

To date, systematic reviews of the literature for persons with NELP or immigrants have focused on access and utilization (5, 47), rather than the broader domains of quality. With significant updates to, and definitions of, quality measures, we can move beyond access and utilization for immigrants and patients with NELP. The objective of this systematic review is to summarize the existing literature on quality of psychiatric care delivery, to determine whether care disparities persist once immigrants and patients with NELP access care.

Methods

We assembled an interdisciplinary team including two psychiatry resident physicians (SS and EM), two internists (MEG and LOF) with expertise in health equity and quality of care for patients with NELP, a psychologist with experience in health informatics and research design (AGD), and a medical informationist (MSP). The study was registered with the International Prospective Register of Systematic Reviews (PROSPERO, ID CRD42023463186).

Eligibility Criteria

The criteria for inclusion was firstly that the study population involved patients with NELP or immigrants, defined as people who are foreign-born relative to the country they live in; secondly, studies involved patients with a mental illness, defined as either having a mental health diagnosis, engaging in outpatient psychiatric care, presenting to the emergency department with a psychiatric chief complaint, or receiving care in a hospital setting for a mental health reason; thirdly studies commenting on the delivery of psychiatric healthcare rather than barriers to accessing or utilizing care; fourthly studies performed in countries where the default language of healthcare delivery is English, and lastly peer-reviewed studies that included original data; all criteria were linked using AND logic. We excluded studies not published in English. We also excluded studies for patients receiving care in non-psychiatric settings and excluded commentaries, expert opinion, or single case reports or series. In order to limit the scope of the study, we excluded studies commenting exclusively on other social determinants of mental health, such as ethnicity and race.

Search Strategy

The search strategy was developed in collaboration with our medical informationist (MSP). We queried four databases: PubMed, PsycINFO, Web of Science, and CINAHL. Manuscripts from August 31, 1993 to August 31, 2023 were considered. The start date was selected to broadly coincide with the availability of the electronic health record (48), and the end date was selected to capture at least 18 months of data after the establishment of standardized quality metrics (46). Our search strategy included keywords and MeSH terms from three categories, linked with AND criteria: immigrant or NELP, mental health, and healthcare quality. For each database, the first category included terms emphasizing immigration status and non-English language preference. The mental health category encompassed MeSH terms for Mental Disorders. The healthcare quality category included broad MeSH terms of healthcare quality and specific measures of psychiatric quality of care such as restraint use and antipsychotic medications. These were selected based off of the domains and sub-domains from past literature on quality measures in psychiatry (44). See supplementary materials for the full search strategy.

Study Selection

We used the Covidence platform (https://www.covidence.org) to screen, review, and extract data for this systematic review. We utilized the Preferred reporting items for systematic reviews and meta-analysis (PRISMA) (49) to report screening results. After we imported identified studies into Covidence, the software automatically detected and removed duplicates. The two reviewers (SS, ME) then manually removed remaining duplicates. Initially, the two reviewers independently screened studies via an abstract review to determine if the studies met the eligibility criteria listed above. Disagreements were resolved with in-person meetings between the reviewers to perform a more in-depth screen of the abstracts together, and the senior author (AGD) resolved any remaining discordances. The reviewers then independently examined the full-text of remaining studies to confirm they met inclusion criteria, again resolving discordances through in-person discussion. The senior author (AGD) was available to resolve any remaining discordances. The interrater reliability was high, with a Cohen’s Kappa of 0.96.

Analysis

Following full text review, the reviewers performed a data extraction of eligible articles, including information on study aims, date range, study population, study setting, primary and secondary outcomes, results, author conclusions, and limitations defined by the authors. We then qualitatively analyzed the data classifying studies in broad categories related to their outcome variables, identified differences in care, and author interpretations of differences. The team categorized all outcome measures into seven broad categories approximately aligning with past literature on quality of care measures, as outlined in the introduction (44): involuntary treatment rate, symptom management, unmet needs, diagnosis, psychiatric referral, medication use, and medication monitoring.

The reviewers also performed a quality assessment of the data, utilizing the Newcastle-Ottawa Scale for assessing the quality of nonrandomized studies (50). In line with this scale, the reviewers gave a score for selection, comparability, and outcome, with a maximum score of four, two, and three, respectively.

Results:

Study Selection and Characteristics

A PRISMA flow diagram and PRISMA-ScR checklist of the study identification, screening, full-text review, and final inclusion data is found in the online supplement. A total of 2860 studies were identified, with the majority from PubMed. CINAHL returned 33 studies meeting the search criteria. After title and abstract screening (Cohen’s Kappa 0.67), the two reviewers performed a full-text review of 65 studies to determine final eligibility. Interrater reliability was strong, with a Cohen’s Kappa of 0.96. The most common reason for excluding a study in the final review was an incorrect study population. A total of 17 studies were included in the systematic review (51–67).

The included studies spanned from 2010–2022, with 13 of the 17 studies published in 2016 or later (55–67). Seven of the manuscripts utilized immigration status to divide the study and comparison populations (53–55, 58, 60, 62, 64), whereas nine of the manuscripts studied populations with NELP (51, 52, 56, 57, 59, 61, 65–67). One study analyzed both country of birth and preferred use of language (63). Six studies were conducted in the United States (51, 52, 56, 65–67), five studies were conducted in Canada (57–59, 62, 64), four in Australia (53, 60, 61, 63), and the remaining two studies were conducted in Ireland (54, 55).

Outcome Measures and Care Differences

A list of studies, results, and outcome measures can be found in Table 1. The most common outcome measure was involuntary treatment rate, with eight studies utilizing this as a proxy for quality of mental healthcare (53–55, 60, 62–64, 66). For each stated outcome, we compiled the statistically significant differences in care between study and comparison populations. Figure 1 displays the number of studies stratified by differences in care and grouped by outcome measure.

Table 1: Included Studies.

The table lists out manuscripts that we included in the final review. The study population group and outcome group were assigned by the reviewers to categorize studies between immigrants and persons with NELP. Abbreviations: NELP non-English language preference. US United States of America. NLAAS National Latino and Asian American Study.

Article	Study Design	Country	Study Population Group	Study Population Determination	Study Population Description	Comparison Group	Measured Outcomes	Outcome Group	Results
Durbin et al. 2017 (57)	Cross-Sectional	Canada	NELP	Self-reported preferred language not English	Patients enrolled in a case management program with NELP	Patients enrolled in a case management program with a preferred language of English	Camberwell needs rating	Unmet Needs	More unmet health needs identified for study population
Bauer et al. 2012 (52)	Experimental	US	NELP	Patient registry preferred language	Received care at one of six community health organizations with preferred language of Spanish	Received care at one of six community health organizations with preferred language of English	Percent of patients prescribed an antidepressant medication at a therapeutic dose	Medication Use	No difference between groups in receipt of antidepressants
Bhalla et al. 2022 (66)	Observational	US	NELP	Electronic Health Record	Patients in the emergency room with a psychiatric complaint and a NELP	Patients in the emergency room with a psychiatric complaint and English preference	Rate of involuntary hospitalization from the emergency department	Involuntary Treatment Rate	No difference in involuntary treatment rate
Stockbridge et al. 2021 (65)	Cross-Sectional	US	NELP	Medical and pharmacy claims data	Medicaid enrollees with schizophrenia or bipolar disorder and taking an antipsychotic medication and a NELP	Medicaid enrollees with schizophrenia or bipolar disorder and taking an antipsychotic medication and an English preference	Percent of patients receiving diabetes screening	Medication Monitoring	More medication monitoring for study population
Chen et al. 2018 (59)	Observational	Canada	NELP	Ontario mental health report system	Patients treated on an inpatient psychiatric unit with a NELP	Patients treated on an inpatient psychiatric unit with an English language preference	Hospital readmission rate within 5 years	Symptom Management	Study population was less likely to be readmitted
Henkhaus et al. 2022 (67)	Cohort	US	NELP	Medicaid enrollment files and Tennessee Department of Health records	Mothers with a Medicaid-covered delivery in Tennessee and a diagnosis of opioid use disorder with a NELP	Mothers with a Medicaid-covered delivery in Tennessee and a diagnosis of opioid use disorder with a preferred language of English	Receipt of medications for opioid use disorder within 30 days of gestation	Medication Use	The study population was less likely to receive medication assistance for opioid use disorder
Rodrigues et al. 2020 (64)	Cohort	Canada	Immigrant	Hospital records	Immigrants aged 16-35 interfacing with the healthcare system in Ontario with a diagnosis of psychosis	Patients who are native-born and aged 16–35 interfacing with the healthcare system in Ontario with a diagnosis of psychosis	Hospitalization rate following psychosis	Involuntary Treatment Rate	The study population was more likely to be psychiatrically hospitalized
Kisely et al. 2020 (63)	Case Control	Australia	NELP & Immigrant	Admitted patient data collection system and Australian Bureau of Statistics	Patients discharged from an inpatient psychiatric unit with either a NELP or an immigrant background	Patients discharged from an inpatient psychiatric unit with either a preferred language of English or no immigrant background	Rate of involuntary community treatment after psychiatric discharge	Involuntary Treatment Rate	Study populations had higher rates of involuntary community treatment than their respective comparison populations
Rodrigues et al. 2019 (62)	Cohort	Canada	Immigrant	Immigration, Refugees, and Citizenship Canada Permanent Resident Database	Patients who are immigrants with an involuntary admission at their first psychiatric hospitalization for psychosis	Patients who are not immigrants with an involuntary admission at their first psychiatric hospitalization for psychosis	Risk of involuntary admission at the first psychiatric hospitalization	Involuntary Treatment Rate	Study populations from African, Caribbean, and East Asian regions were more likely to be involuntarily admitted for psychosis than their non-migrant counterparts
Daly et al. 2019 (61)	Observational	Australia	NELP	Health record of interpreter use	Patients admitted to psychiatry a need for a language interpreter	Patients to psychiatry without a need for a language interpreter	Psychiatric consultant referral and frequency of personality disorder diagnosis at discharge	Referral & Diagnosis	The study population had more referrals and lower rates of personality disorder diagnosis
Kisely et al. 2018 (60)	Case Control	Australia	Immigrant	Australian Bureau of Statistics data	Patients admitted to psychiatry with community follow up with a place of birth outside of Australia, New Zealand, or the British Isles	Patients admitted to psychiatry with community follow up with a place of birth of Australia, New Zealand, or the British Isles	Rate of involuntary community treatment after mental health admission	Involuntary Treatment Rate	The study population was more likely to be placed in involuntary community treatment after discharge
Abdel-Baki et al. 2018 (58)	Cohort	Canada	Immigrant	Self-report of geopolitical region of birth	First-generation immigrant patients with a diagnosis of first-episode psychosis seen in the early intervention service	Non-immigrant patients with a diagnosis of first-episode psychosis seen in the early intervention service	Depressive symptoms and rate of substance use disorder diagnosis 24 months after first-episode psychosis	Symptom Management & Diagnosis	The study population had higher depressive scores at two years of treatment compared to native-born population. They also had lower rates of being diagnosed with a substance use disorder
Herbst et al. 2016 (56)	Cross-Sectional	US	NELP	Electronic Health Record	Patients with a NELP receiving a mental health consultation in the pediatric clinic	Patients with a preferred language of English receiving a mental health consultation in the pediatric clinic	Rate of formal referral to mental health	Referral	The study population was less likely to get a mental health consult or be given a referral for a mental health diagnosis
Curley et al. 2016 (55)	Observational	Ireland	Immigrant	2011 Irish National Census Data	Patients admitted to psychiatry with a place of origin outside of Ireland	Patients admitted to psychiatry with a place of origin of Ireland	Rate of involuntary admission	Involuntary Treatment Rate	The study population was more likely to be admitted involuntarily.
Kelly et al. 2015 (54)	Observational	Ireland	Immigrant	2011 Irish National Census Data	Patients admitted to the psychiatric service at the University Hospital with a country of origin outside of Ireland	Patients admitted to the psychiatric service at the University Hospital with a country of origin of Ireland	Rate of involuntary admission	Involuntary Treatment Rate	The study population was more likely to be admitted involuntarily.
Nielssen et al. 2013 (53)	Observational	Australia	Immigrant	Electronic Health Record	Patients admitted to the mental health unit in a public hospital with a country of birth outside of Australia or New Zealand	Patients admitted to the mental health unit in a public hospital with a country of birth of Australia or New Zealand	Rate of involuntary admission	Involuntary Treatment Rate	The study population was more likely to be admitted involuntarily.
Bauer et al. 2010 (51)	Observational	US	NELP	Self-report from NLAAS Survey	Non-institutionalized adults participating in the NLAAS Survey with a mental health diagnosis for at least 12 months with self-reported NELP.	Non-institutionalized adults participating in the NLAAS Survey with a mental health diagnosis for at least 12 months with self-reported English language preference	Rate of patients meeting minimally adequate standard of care	Symptom Management & Unmet Needs	No difference in minimally adequate care between the study and comparison population

Figure 1: Differences in Care, by Outcome.

Lists the number of studies commenting on each outcome group. Shaded area refers to identified areas where there were care differences between the study and comparison populations.

Involuntary Treatment Rate:

The most established care difference was in the involuntary treatment rate for the immigrant study population, with higher rates of compulsory treatment identified for immigrants compared to native-born individuals in all included studies. No difference in care was identified in the included study for patients with NELP (66).

Symptom management:

This outcome measure encompassed studies using a variety of endpoints, including standardized depressive scores and readmission rates. Differences in care were noted in included studies, though only three studies identified symptom management as an endpoint (51, 58, 66).

Unmet needs:

Two studies identified a gap in psychiatric care delivery for patients with NELP compared to patients who are English-speaking, including differences in perceived need for further treatment or unmet psychological needs (51, 57).

Medication Use:

Two studies commented on the use of psychotropic medication for patients with NELP. One revealed a difference in the utilization of medication assistance for opioid use disorders (67) whereas a different study showed no difference in utilization of medications by language (52).

Diagnosis:

Two studies indicated differences in the prevelance of diagnoses given, with these study populations being less likely to have a diagnosis of a personality disorder (61) or to have diagnoses of substance use disorders (58).

Medication Monitoring:

Only one study was identified that compared adherence to metabolic monitoring guidelines (65). People with an English preference did not have higher rates of monitoring compared to people with NELP.

Psychiatric Referral:

One study found patients with a Spanish-language preference were less likely to receive a referral for psychotropic medication consult compared to patients with a English-language preference (56).

Study Conclusions

See Figure 2 for the most common study interpretations of differences in care. The most common interpretation for any identified care disparities was differences in help-seeking patterns between the study populations and comparison population. Two of the seventeen studies commented on the role of perceived discrimination in the delivery of mental healthcare. Specifically, one study discussed the role of perceived discrimination for people from linguistically diverse backgrounds as a deterrent to care and another discussed this in the context of immigration status.

Figure 2: Study Attributions to Differences.

Lists the most common attributions for differences in care. We indicated the frequency in which these attributions were cited in the included studies.

Identified Limitations and Quality Assessment

The most common author-identified limitation was low generalizability from a single healthcare system analysis. Other commonly listed limitations included the possibility of confounding social determinants of health and heterogeneity of the study population group. More specifically, four studies indicated that the study populations may be disproportionately affected by other social determinants of health. Four studies focused on the immigrant population commented on the diversity of experiences within the immigrant study group, both in emigration location and reason for traveling, such as the difference between a tourist and a refugee.

The quality assessment results can be found in Table 2. Fifteen studies scored 3 or above in selection (52–57, 59–67). Only three studies scored maximully for comparability (56, 66, 67). In terms of outcome, eight of the seventeen studies (53, 54, 58, 59, 61, 62, 64, 65) were below a score of 2.

Table 2: Quality Assessment.

Displays the results of the Newcastle-Ottawa Scale (50). The maximum score for selection was four, comparability was two, and outcome was three.

Article	Selection	Comparability	Outcome
Durbin et al. 2017 (57)	3	1	2
Bauer et al. 2012 (52)	4	1	2
Bhalla et al. 2022 (66)	4	2	2
Stockbridge et al. 2021 (65)	4	1	1
Chen et al. 2018 (59)	4	0	1
Henkhaus et al. 2022 (67)	4	2	2
Rodrigues et al. 2020 (64)	3	1	1
Kisely et al. 2020 (63)	4	1	2
Rodrigues et al. 2019 (62)	3	1	1
Daly et al. 2019 (61)	3	1	1
Kisely et al. 2018 (60)	4	1	2
Abdel-Baki et al. 2018 (58)	2	1	1
Herbst et al. 2016 (56)	4	2	2
Curley et al. 2016 (55)	4	1	2
Kelly et al. 2015 (54)	4	1	1
Nielssen et al. 2013 (53)	4	1	1
Bauer et al. 2010	1	0	2

Discussion

In our systematic review, we found compelling evidence for differences in involuntary treatment rates for immigrant populations compared to a representative native-born population, with a difference identified in six of the six included studies. Yet this difference was not reported/found for persons with NELP. Our review indicated that it is possible there is a difference in symptom management, though the few numbers of studies for immigrants and people with NELP limited drawing a definitive conclusion. Similarly, given the few studies and mixed evidence for differences in care for other quality domains, the current literature does not allow for further conclusions.

Two prior reviews (5, 47) attempted to quantify differences in care for persons with NELP and immigrants in 2015 and 2016, respectively. Both studies presented evidence that study populations accessed health services at lower rates than a representative comparison sample and identified a need for further research. The creation of more standardized quality metrics since the publication of these reviews highlighted the need for an updated review (44, 46) to explore if and how psychiatric care quality differs for persons with NELP and immigrants.

Importantly, while this systematic review comments on differences in care beyond access and utilization, the limited number of studies and the heterogeneity in outcome measures limits any conclusions on whether persons with NELP or immigrants receive worse psychiatric care than a representative comparison population. The most commonly utilized outcome measures in included studies are only tangentially related to the quality of mental healthcare delivery, and thus require careful interpretation. For example, the difference in involuntary treatment rate could be attributed to implicit provider bias, such as a provider assuming in their risk assessment that immigrants would have a lower support network in the country, and thus compel them towards involuntary hospitalization (62, 68). However, this difference in treatment rate could also reflect the established decreased rate of access to outpatient care (4), leading to increased severity of symptoms at presentation. Moreover, involuntary treatment remains a last-line intervention for severe mental illness and an important part of psychiatric care, including quality psychiatric care (69). Thus, there is a compelling argument that involuntary treatment does not represent worse care, but rather that it could represent treating severe mental illness symptoms before patients can harm themselves or others. Similar arguments can be made for other outcome measures from the current literature. In terms of utilizing psychotropic medications to treat mental illness, differences in care could represent a decrease in clinicians offering medications to our populations of interest. However, the difference could also represent cultural preferences against using medications for mental health, and thus clinicians not prescribing psychotropic medications could represent shared decision-making and patient-centered care.

Broadly, with the establishment of quality domains by authors such as Goldman et al. and organizations like the American Psychiatric Association (44, 46), quality measures and the utilization of measurement-assisted care is becoming more prevalent in psychiatric practice. There is a higher emphasis on consistent medication monitoring, the completion of patient assessment tools for symptom tracking, and improving patient-reported outcomes. However, there is still a lack of studies utilizing these metrics, and, as stated by Kilbourne et al, “we cannot improve what we cannot measure” (43).

While analyzing the conclusions of included studies poses challenges, one clear takeaway is that there should be minimal differences in care based on either language preference or immigration, and exploring the reasons for these differences remains an important question. In terms of barriers to care, many studies alluded to patient-level characteristics such as differences in healthcare-seeking attitudes. Termed the “downstream effect” risk factors in past literature (70), these are important factors to consider as they highlight how cultural differences can impact care in many ways. However, in addition to these explanations, we emphasize the importance of expanding this framework to look at all aspects of the mental healthcare ecosystem. Differences in cultural values between patients and providers, the possibility of miscommunication, and the interplay of other social determinants of mental health, all likely contribute to differences in care. These and other structural barriers, such as difficiutlies with consistent interpreter use, must also be considered when attempting to improve health equity for these populations.

Our systematic review has limitations. The heterogeneity of the outcome measures and relatively low numbers of studies precluded a meta-analysis and quantifying outcomes. The low number of studies assessing care for immigrant populations limited drawing broad conclusions for this group. As stated above, to limit the scope of this study, the search strategy intentionally did not include other co-occurring social determinants of health, such as ethnicity and race. We additionally limited our strategy to only include countries where the predominant language of healthcare delivery was English, which prevented us from commenting on differences in care for many countries. The variability in outcome measures also limited our conclusions. With an overall lack of literature on established quality metrics in psychiatry, we are unable to determine whether disparities in care exist, and rather can only comment on differences. Lastly, the lack of a consistent definition of NELP and the significant variation in methods to determine immigrant status limited generalizability between studies.

Ultimately, the current literature suggests that psychiatry is making great strides in defining quality measures for mental healthcare. Yet there is an unmet research need for studies to use predefined psychiatric quality parameters to quantify disparities. The current literature remains inconclusive on the quality of psychiatric care delivery, which makes it difficult for health systems to address potential gaps in care. Additional studies should evaluate quality of care received by these populations, utilizing standardized measures of mental healthcare quality, such as medication monitoring, delivery of patient assessment tools, and patient-reported outcomes.

Conclusions

In conclusion, this review originally aimed to identify quality of care disparities for immigrants and populations with NELP, uniquely focusing on psychiatric healthcare delivery rather than access and utilization. Although we identified differences in involuntary mental health treatment rate for the immigrant population, our findings also highlighted that current outcome measures remain tangentially related to quality of psychiatric care. Thus, there is insufficient data to determine if an established gap in care delivery exists for immigrants and patients with NELP. Studies evaluating established psychiatric quality metrics as outcome variables, such as medication monitoring adherence and mental health assessment rates, are needed to better assess quality of care and any delivery disparities that may exist for immigrants and patients with NELP.

Highlights:

• This review examines mental healthcare quality for immigrants and persons with non-English language preference. Among 2860 studies from four databases, 17 were reviewed, showing variability in quality measures.

• Immigrants were more likely to receive involuntary treatments in seven of seven studies, but other outcomes were underexplored.

• Determining care gaps requires standardized quality measures in future studies.