The place of culture in DSM-IV

Cultural relevance and equivalence in the NLAAS instrument: integrating etic and emic in the development of cross-cultural measures for a psychiatric epidemiology and services study of Latinos

This paper describes the development, translation and adaptation of measures in the National Latino and Asian American Study (NLAAS). We summarize the techniques used to attain cultural relevance; semantic, content and technical equivalency; and internal consistency of the measures across languages and Latino sub-ethnic groups. We also discuss some of the difficulties and thallenges encountered in doing this work. The following three main goals are addressed in this paper: (1) attaining cultural relevance by formulating the research problem with attention to the fundamental cultural and contextual differences of Latinos and Asians as compared to the mainstream population; (2) developing cultural equivalence in the standardized instruments to be used with these populations; and (3) assessing the generalizability of the measures - i.e., that the measures do not fluctuate according to culture or translation. We present details of the processes and steps used to achieve these three goals in developing measures for the Latino population. Additionally, the integration of both the etic and emic perspectives in the instrument adaptation model is presented.

Psychosocial factors in chronic fatigue syndrome among Chinese Americans: a longitudinal community-based study

Chronic fatigue syndrome (CFS) is a relatively new condition of unknown etiology. Research suggests that psychosocial factors such as perceived social support, life stress, and acculturation may significantly influence individuals who are prone to CFS. For 57 Chinese American individuals initially diagnosed with CFS, those who recovered after one year reported lower levels of life stress than those who did not recover. Effects of changes in perceived social support also appeared to be mediated by life stress.

Culture and validity of the Symptom Checklist-90-Revised and Profile of Mood States in a New Zealand student sample

New Zealand students' performance was examined on assessments of psychopathology and mood as compared to normative data from the United States. New Zealand university students (N = 137) completed the Symptom Checklist-90-Revised (SCL-90-R) and Profile of Mood States (POMS). Mean performances differed significantly from normative data for each SCL-90-R scale. No significant differences were found for the POMS scales. Within the sample, European (n = 82), Maori (n = 24), and Asian (n = 24) participants differed significantly on SCL-90-R obsessive-compulsive, phobic anxiety, and anxiety scales and POMS scales of tension and confusion. Implications for assessment of New Zealand samples are discussed.

The APA classification of mental disorders: future perspectives

After 8-10 years of experience with the fourth edition of the Diagnostic and Statistical Manual (DSM-IV) and the tenth edition of the International Classification of Diseases (ICD-10), it is an ideal time to begin looking at the clinical and research consequences of these diagnostic systems. The American Psychiatric Association, in conjunction with the National Institutes of Health, has initiated a research development process intended to accelerate an evaluation of existing criteria while developing and testing hypotheses that would improve the validity of our diagnostic concepts. Over the past year, a multidisciplinary, international panel has developed a series of six white papers which define research opportunities in the following broad areas: Nomenclature, Disability and Impairment, Personality Disorders, Relational Disorders, Developmental Psychopathology, Neuroscience, and Cross-Cultural aspects of Psychopathology. Recommendations for future national and international research in each of these areas will be discussed.

Socio-cultural and global health perspectives for the development of future psychiatric diagnostic systems

Psychiatric diagnosis and classification reflect the social and political context of an era and are embedded in it. In the last few decades, culture-bound syndromes reported in non-Western societies constituted the major focus of contention over the validity and universality of psychiatric diagnosis. In contemporary times, social, economic, and political factors, such as the hegemony of the DSM discourse, the managed care culture, pharmaceutical forces, and the global burden of disease study, have virtually made culture-bound syndromes 'disappear'. Once widely believed to be rare outside of the developed West, depression has rapidly become the master narrative of mental health worldwide. In the context of global mental health, the field of psychiatric classification must go beyond routine debates over categories. In order to address the growing discrepancy between needs and services, international cultural psychiatry must engage key social forces, such as psychiatric epidemiology, primary care psychiatry, integration of diagnostic systems, stigma, and advocacy.

Multiethnic comparison of adolescent major depression based on the DSM-IV criteria in a U.S.-Japan study

OBJECTIVES

To compare the prevalence rates of major depression based on the DSM-IVcriteria with data from a multiethnic sample of adolescents drawn from the same U.S.-Japan study and to investigate the relation of adolescent major depression to ethnicity.

METHOD

Adolescents aged 12-15 years (N= 2,046; 539 Anglo-American, 636 African-American, 409 Mexican-American, and 462 Japanese adolescents) were studied in 1994 (response rates: 85.3% for U.S. students and 95.5% for Japanese students). The DSM Scale for Depression, a self-administered checklist developed from the Diagnostic Interview Schedule for Children questions on major depression, was used to estimate the prevalence of DSM-IV major depression.

RESULTS

The overall prevalence rates of major depression without/with impairment were 9.6% and 4.3% for Anglo-American, 13.4% and 6.1 % for African-American, 16.9% and 9.0% for Mexican-American, and 5.6% and 1.3% for Japanese adolescents. The significant association between adolescent major depression and ethnicity disappeared after sociodemographic adjustments. Only fathers' educational attainment and family financial status remained significant (odds ratios: 3.28-5.30 for grade school for fathers and 2.62-2.78 for being worse off economically).

CONCLUSION

These findings imply ethnicity does not have a significant impact on the risk of adolescent major depression after sociodemographic adjustments.

Culture in DSM-IV, ICD-10, and evolving diagnostic systems

The past decade has shown interesting attempts to articulate the cultural framework of psychiatric diagnosis. Most distinctive in this regard has been the culture presence in DSM-IV. Less substantial concerning culture has been the core ICD-10. Of high cultural interest are the national and international adaptations of ICD-10 because of their aim at articulating universality with local realities and needs. The WPA International Guidelines for Diagnostic Assessment exhibits an innovative diagnostic system that combines standardized multiaxial and personalized idiographic formulations with pointed attention to culture considerations. Finally, this article outlines some culture-informed recommendations for the development of future diagnostic systems.

Cultural psychopathology: uncovering the social world of mental illness

We review cultural psychopathology research since Kleinman's (1988) important review with the goals of updating past reviews, evaluating current conceptualizations and methods, and identifying emerging substantive trends. Conceptual advances are noted, particularly developments in the definition of culture and the examination of both culture-specific and cultural-general processes. The contributions of the Culture and Diagnosis Task Force for DSM-IV and the World Mental Health Report are reviewed and contrasted. Selected research on anxiety, schizophrenia, and childhood disorders is examined, with particular attention given to the study of ataque de nervios, social factors affecting the course of schizophrenia, and cross-national differences in internalizing and externalizing problems in children. Within the last ten years, cultural psychopathology research has become a significant force. Its focus on the social world holds promise to make significant inroads in reducing suffering and improving people's everyday lives.

The structure of attention-deficit and hyperactivity symptoms among native and non-native elementary school children

This study evaluated the psychometric properties of a measure of Attention-Deficit/Hyperactivity Disorder (ADHD) with Native and non-Native children. Two models, corresponding to DSM-III-R and DSM-IV symptom categorizations of ADHD, were assessed by (a) determining which DSM schema of ADHD best fit the data within each culture group and (b) testing the cross-cultural equivalence of the best-fitting model. Data were taken from the Flower of Two Soils and School Options for Native Children studies, examinations of emotional health and academic achievement among Native and non-Native children. The studies included teacher, parent, and self-report ratings of symptoms among 1555 Native and 489 non-Native children in grades 2 and 4 at four different locations across North America. For the data derived from teacher and parent ratings, a 2-factor solution corresponding to the DSM-IV conceptualization of two subtypes provided the best fit. For student self-ratings, the 2-factor solution showed no improvement over a 1-factor model. The respective factor solutions were culturally invariant. Acceptable internal consistency was observed across raters and within culture groups.

Mental health services for American Indians and Alaska Natives: need, use, and barriers to effective care

This special review summarizes and illustrates the state of our knowledge regarding the mental health needs of American Indians and Alaska Natives. These needs are considerable and pervasive. The discussion begins by reflecting on the limits of psychiatric nomenclature and conceptual frameworks for revealing Native constructions of mental health and mental illness. The experience and manifestation of psychopathology can be both different and the same across cultures, hinging upon the extent to which such basic assumptions as the relationship of mind to body--and spirit in the case of Native people--or the primacy of the individual or social collective are shared. Having set the stage, this paper moves to recent empirical evidence regarding the mental health needs of American Indians and Alaska Natives: we review that evidence and consider it within the broader context of available services. The report closes with a brief overview of the most pressing issues and forces for change afoot in Indian country in the US. Most have to do with the structure and financing of care as tribes and other Native community-based organizations seek to balance self-determination and resource management to arrive at effective, fiscally responsible, culturally informed prevention, treatment, and aftercare options for their members. These changes may herald similar trends among First Nations people to the immediate north.

The future of cultural psychiatry: an international perspective

Cultural psychiatry has evolved along 3 lines: 1) cross-cultural comparative studies of psychiatric disorders and traditional healing; 2) efforts to respond to the mental health needs of culturally diverse populations that include indigenous peoples, immigrants, and refugees; and 3) the ethnographic study of psychiatry itself as the product of a specific cultural history. These studies make it clear that culture is fundamental both to the causes and course of psychopathology and also to the effectiveness of systems of healing. The provision of mental health services in multicultural societies has followed different models that reflect their specific histories of migration and ideologies of citizenship. Globalization has influenced psychiatry through socioeconomic effects on the prevalence and course of mental disorders, changing notions of ethnocultural identity, and the production of psychiatric knowledge. A cultural perspective can help clinicians and researchers become aware of the hidden assumptions and limitations of current psychiatric theory and practice and can identify new approaches appropriate for treating the increasingly diverse populations seen in psychiatric services around the world.