Message Framing and Engagement in Specialty Mental Health Care: A Follow-up Analysis

Attendance rates in specialty mental health treatment are suboptimal, with many individuals neither initiating treatment nor engaging in continued mental health care (1). A variety of strategies to improve attendance rates have been developed and examined. For example, multicomponent care management strategies that use tailored feedback, motivational techniques, and tracking of outcomes can lead to significant improvements in initial and sustained treatment engagement (2). However, these strategies are both time intensive and staff intensive, and not all clinical settings have adequate resources to track and manage all patients referred to specialty mental health care. Less intensive strategies, including delivering automated prompts and appointment reminders by means of telephone, text, or postal mail, also have been shown to improve attendance rates among patients, representing potentially brief, effective, and low-cost methods of improving engagement (3).

Similar to other health behaviors, seeking treatment for mental health concerns is guided by cognitive processes related to both motivation and decision making. Thus one cognitively centered approach that has the potential to motivate patients to engage in treatment involves manipulating the phrasing—or “framing”—of the health recommendation (4–6). For example, varying the extent to which a health appeal highlights the benefits of performing a specific behavior (that is, a gain-framed appeal; “by exercising, you increase your chances of keeping your blood pressure under control”) or the costs of not performing the behavior (that is, a loss-framed appeal; “by not exercising, you decrease your chances of keeping your blood pressure under control”) has been found to influence both intention to change and actual engagement in a range of health behaviors (for example, mammography and breast self-examination, sunscreen use, HIV testing, and smoking cessation) (4,7–9).

Guided by empirical support for the impact of message framing on health behavior and the effectiveness of appointment reminder letters in improving treatment attendance rates among patients with mental illness (3,10), we conducted a randomized study to examine the relative effect of loss-framed, gain-framed, and neutral messages on mental health treatment initiation and engagement for up to six months following a positive result on a depression screen (11). Primary analyses revealed that patients who received a gain-framed appointment reminder letter prior to their first scheduled specialty care visit were significantly more likely to attend their appointment than those who were randomly assigned to receive a neutral, standard appointment reminder letter. There were no significant differences, however, in appointment attendance rates across patients receiving a loss-framed reminder letter and those receiving a gain-framed or a neutral letter. In this report, we examine the relative effect of message frame on the rate of engagement in specialty care appointments over a six-month period following the initial referral. According to prospect theory, individuals act to avoid risks when presented with potential gains or benefits but are more willing to take risks when presented with potential losses or costs associated with engaging in a behavior (12). Given that attending mental health care appointments can result in a variety of desirable outcomes, or gains (for example, maintenance of mental health, prevention of further, more severe impairment, and alleviation or remission of depressive symptoms), we hypothesized that patients who received gain-framed messages would be significantly more likely to attend their scheduled appointments than those receiving a loss-framed or neutral letter.

Methods

A detailed description of all study methods is available elsewhere (11) and is briefly outlined here. The sample included 360 veterans receiving care at the Corporal Michael J. Crescenz Veterans Affairs Medical Center (CMCVAMC), located in Philadelphia, and affiliated community-based outpatient clinics who completed a behavioral health assessment by the Behavioral Health Laboratory (BHL) between March 30, 2015, and September 29, 2016. The BHL is a clinical management program that focuses on the identification, screening, and assessment of primary care patients who may be in need of care for behavioral health issues such as depression, anxiety, alcohol misuse, and posttraumatic stress disorder (PTSD) (13). The BHL is used to triage all veterans seeking mental health care at the CMCVAMC.

To be included in the study, patients must have met the criteria for major depression based on the Patient Health Questionnaire-9 scale (14) with or without a co-occurring disorder (that is, meeting the DSM-5 criteria for PTSD, bipolar disorder, psychosis, or substance use disorder) upon BHL assessment; had not seen a specialty mental health care provider in the prior six months; and accepted a specialty mental health care appointment scheduled at the completion of the BHL clinical interview. Patients were excluded from the study if they had cognitive, hearing, or other impairments leading to difficulty with the initial BHL assessment.

A random number table was used to randomly assign all eligible patients to receive one of three appointment reminder letters prior to their mental health care appointments scheduled for up to six months following the initial BHL referral. Charts were checked monthly for upcoming appointments. One-third of the patients (N=120) were sent a routine clinical reminder letter with the name of the provider, date and time of the scheduled specialty mental health care visit, and directions to the hospital and clinic (neutral arm). The other two-thirds of the patients were randomly assigned to receive reminder letters that were modified to include a gain-framed (N=120; gain-framed arm) or loss-framed (N=120; loss-framed arm) message or appeal (Table 1).

The gain-framed and loss-framed messages were developed based on a review of the message framing literature and finalized upon consensus of an expert panel of CMCVAMC mental health providers and veterans (4,6,15). Gain-framed and loss-framed messages were included at the top of the routine appointment letters in bold font. Each letter was mailed so that it would be delivered approximately 1–3 days before the scheduled appointment (3). Patients’ scheduled and attended appointments were tracked using electronic queries of computerized patient records and entered into a research database. Given the study design and minimal risks to participants, we requested a waiver of informed consent. The local institutional review board approved all study procedures.

Data on sociodemographic variables were collected as part of the clinical BHL interview and included age, gender, race-ethnicity, marital status, and financial status. Data on patient self-reported mental health symptoms (such as depression, anxiety, and PTSD) and overall mental and physical functioning also were collected as part of the clinical BHL interview and extracted for analysis of baseline group characteristics.

Data on specialty mental health care appointment schedules and attendance were collected through electronic queries of computerized patient records. We extracted data on the date and attendance status of appointments scheduled for up to six months following the initial BHL referral. Attendance at each appointment was recorded as a dichotomous variable (0, patient did not attend the scheduled appointment; 1, patient attended the scheduled appointment). Cases where the clinic (not the patient) cancelled the appointment were evenly distributed across randomization arms and were removed from the analysis.

In addition to descriptive, univariate analyses, analysis of variance (ANOVA) and chi-square tests were run to examine baseline group differences in sociodemographic and clinical variables (per the BHL interview) across randomization arms. Next we ran a generalized estimating equation model that examined the association between message frame (three levels: neutral versus gain versus loss) and attendance at the corresponding scheduled appointment (binary variable) over the six-month period. Comparisons of attendance rates were made across all three groups. The model adjusted for correlated observations and the log of the total number of scheduled appointments for each patient over the six months.

Results

The sample was primarily male (N=307, 85%) and non-Hispanic black (N=196; 54%); the remainder of the sample was non-Hispanic white (N=135, 38%); Hispanic (N=17, 5%); American Indian, Native Alaskan, Native Hawaiian, or other Pacific Islander (N=4, 1%); Asian (N=3, 1%); or other race-ethnicity (N=5, 1%). The mean±SD depressive symptom score on the Patient Health Questionnaire–9 was 19.3±3.8 (range 9–27), with higher scores indicating greater symptom severity. There were no significant differences across groups in any of the clinical and background characteristics (11). Patients assigned to receive gain-framed messages prior to their appointments over the six-month period were significantly more likely to attend the scheduled appointment than those assigned to receive the neutral letter (odds ratio=1.52; 95% confidence interval=1.11–2.08; p=.01). However, there were no significant differences in attendance rates across patients receiving loss-framed messages and patients receiving gain-framed or neutral messages.

Discussion

Results from this analysis of the association between message framing and specialty mental health care appointment attendance further support the idea that adding a brief, positive, gain-framed message to a routine appointment reminder letter is associated with increased attendance rates over time. The results are an extension of our previous finding that patients sent a reminder letter that includes a gain-framed message are also more likely than those sent a neutral or loss-framed message to attend their initial visit in specialty mental health care (11). As previously mentioned, prospect theory posits that individuals will be risk averse when presented with future gains or benefits associated with engaging in a target behavior but are more likely to take risks when presented with future losses or costs associated with a behavior (12). Using this as a context, it is possible that patients did not perceive the consequences of attending specialty mental health care appointments as being risky or uncertain, as one might expect when engaging in a screening behavior that could result in the detection of a health condition (for example, undergoing cancer screening). Rather, patients may have perceived engaging in specialty care as being a preventative or recuperative behavior that would result in positive outcomes or gains, such as prevention of further impairment, reduction in symptoms, and improved functioning. Although detection behaviors have been shown to be more responsive to loss-framed messages, preventative behaviors (for example, exercise, sunscreen use) and recuperative behaviors (for example, treatment engagement) that result in positive outcomes, or gains, are more responsive to gain-framed messages (4,9). Thus it stands to reason that our sample of patients may have been more responsive to the gain-framed messages to the extent that they perceived their attendance at scheduled appointments as a recuperative or preventative behavior. Finally, framing the message in a positive way also may have overcome some of the motivational challenges that are often associated with depression (15).

Although the findings support our hypothesis, a number of factors should be taken into account when considering the results. First, the study findings may not generalize to all individuals with depression or to patients receiving care from other health care settings. For example, the racial-ethnic composition of the CMCVAMC patient population and our sample’s high rates of psychiatric comorbidity may not be representative of other health care settings. Second, our analyses did not adjust for other important variables that are associated with mental health care engagement (and in some cases, responsiveness to message frames), such as co-occurring conditions and symptom severity over the course of the six-month follow-up period, the time of day and the day of the week that the appointment was scheduled, the patients’ geographic distance to the clinic, patients’ prior history with and perceptions of behavioral health conditions and specialty care, perceived social stigma surrounding mental health care, or patients’ general perceptions of VA health care access and quality. Finally, we had no way of verifying that patients received and read each of their appointment reminder letters.

Conclusions

Notwithstanding these caveats, the study findings have numerous potential applications in current practice and in future work. Modifying standard appointment reminder notices, which many health systems use, to clearly highlight the potentially positive, as opposed to negative, consequences of attending a specialty mental health care appointment may improve engagement rates in a timely, efficient, and cost-effective manner. Although this study utilized paper reminder letters sent by mail, future studies may examine the effect of modifying message frames by using different modes of message delivery at the individual level (for example, telephone reminders and text-based or Web-based prompts) and within different contexts (such as broader, system-level visual, print, or digital public health communications and social marketing campaigns). Moreover, although this study focused on veterans who had a positive screen for major depression, future studies replicating this work among patients with other mental health conditions (such as anxiety) that also take into account potential moderators (for example, perceived stigma and perceived risk associated with engaging in the behavior) are warranted, because individuals with other health conditions may respond differently to various message frames. Finally, although the results presented here are specific to the effect of positive and negative message frames on engagement in specialty mental health care, the findings lend support for future studies that more broadly explore variation in the types of communication strategies providers naturally use during patient-provider encounters and the effect that those strategies have on patients’ observed behavior.