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Kwobah EK, Goodrich S, Kulzer JL, Kanyesigye M, Obatsa S, Cheruiyot J, Kiprono L, Kibet C, Ochieng F, Bukusi EA, Ofner S, Brown SA, Yiannoutsos CT, Atwoli L, Wools-Kaloustian K. Adaptation of the Client Diagnostic Questionnaire for East Africa. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0001756. [PMID: 38502647 PMCID: PMC10950255 DOI: 10.1371/journal.pgph.0001756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 02/17/2024] [Indexed: 03/21/2024]
Abstract
Research increasingly involves cross-cultural work with non-English-speaking populations, necessitating translation and cultural validation of research tools. This paper describes the process of translating and criterion validation of the Client Diagnostic Questionnaire (CDQ) for use in a multisite study in Kenya and Uganda. The English CDQ was translated into Swahili, Dholuo (Kenya) and Runyankole/Rukiga (Uganda) by expert translators. The translated documents underwent face validation by a bilingual committee, who resolved unclear statements, agreed on final translations and reviewed back translations to English. A diagnostic interview by a mental health specialist was used for criterion validation, and Kappa statistics assessed the strength of agreement between non-specialist scores and mental health professionals' diagnoses. Achieving semantic equivalence between translations was a challenge. Validation analysis was done with 30 participants at each site (median age 32.3 years (IQR = (26.5, 36.3)); 58 (64.4%) female). The sensitivity was 86.7%, specificity 64.4%, positive predictive value 70.9% and negative predictive value 82.9%. Diagnostic accuracy by the non-specialist was 75.6%. Agreement was substantial for major depressive episode and positive alcohol (past 6 months) and alcohol abuse (past 30 days). Agreement was moderate for other depressive disorders, panic disorder and psychosis screen; fair for generalized anxiety, drug abuse (past 6 months) and Post Traumatic Stress Disorder (PTSD); and poor for drug abuse (past 30 days). Variability of agreement between sites was seen for drug use (past 6 months) and PTSD. Our study successfully adapted the CDQ for use among people living with HIV in East Africa. We established that trained non-specialists can use the CDQ to screen for common mental health and substance use disorders with reasonable accuracy. Its use has the potential to increase case identification, improve linkage to mental healthcare, and improve outcomes. We recommend further studies to establish the psychometric properties of the translated tool.
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Affiliation(s)
- Edith Kamaru Kwobah
- Department of Mental Health, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Suzanne Goodrich
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Jayne Lewis Kulzer
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | | | - Sarah Obatsa
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Lorna Kiprono
- Academic Model Providing Access to Care, Eldoret, Kenya
| | - Colma Kibet
- Academic Model Providing Access to Care, Eldoret, Kenya
| | - Felix Ochieng
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Elizabeth A. Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Susan Ofner
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Steven A. Brown
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Constantin T. Yiannoutsos
- Department of Biostatistics and Health Data Science, Indiana University Fairbanks School of Public Health, Indianapolis, Indiana, United States of America
| | - Lukoye Atwoli
- Department of Mental Health and Behavioral Sciences, Moi University School of Medicine, Eldoret, Kenya
- Brain and Mind Institute and the Department of Internal Medicine, Medical College East Africa, Aga Khan University, Nairobi, Kenya
| | - Kara Wools-Kaloustian
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
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Xavier SM, Jarvis GE, Ouellet-Plamondon C, Gagné G, Abdel-Baki A, Iyer SN. Comment les services d’intervention précoce pour la psychose peuvent-ils mieux servir les migrants, les minorités ethniques et les populations autochtones ? SANTE MENTALE AU QUEBEC 2021. [DOI: 10.7202/1088188ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Bardol O, Grot S, Oh H, Poulet E, Zeroug-Vial H, Brunelin J, Leaune E. Perceived ethnic discrimination as a risk factor for psychotic symptoms: a systematic review and meta-analysis. Psychol Med 2020; 50:1077-1089. [PMID: 32317042 DOI: 10.1017/s003329172000094x] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Previous studies have shown an elevated risk of psychotic symptoms (PS) and experiences (PEs) among ethnic minority groups, with significant variation between groups. This pattern may be partially attributable to the unfavorable socio-environmental conditions that surround ethnic minority groups. Perceived ethnic discrimination (PED) in particular has been a salient putative risk factor to explain the increased risk. METHODS We conducted a systematic literature review and meta-analysis to assess the impact of PED on reporting PS/PEs in ethnic minorities. This review abides by the guidelines set forth by Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The included studies were obtained from the databases: Medline, PsycINFO, and Web Of Science. Sub-group analyses were performed assessing the effect of PED in different subtypes of PS, the influence of ethnicity and moderating/mediating factors. RESULTS Seventeen studies met the inclusion criteria, and nine were used to conduct the meta-analysis. We found a positive association between PED and the occurrence of PS/PEs among ethnic minorities. The combined odds ratio were 1.77 (95% CI 1.26-2.49) for PS and 1.94 (95% CI 1.42-2.67) for PEs. We found that the association was similar across ethnic groups and did not depend on the ethnic origin of individuals. Weak evidence supported the buffering effects of ethnic identity, collective self-esteem and social support; and no evidence supported the moderating effect of ethnic density. Sensitivity to race-based rejection significantly but only slightly mediated the association. CONCLUSION These findings suggest that PED is involved in the increased risk of PS/PEs in ethnic minority populations.
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Affiliation(s)
- Olivier Bardol
- Grenoble Alpes University, School of Medicine, Grenoble, France
| | - Stéphanie Grot
- Centre de recherche, Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada
| | - Hans Oh
- University of Southern California, Los Angeles, USA
| | - Emmanuel Poulet
- Centre Hospitalier Le Vinatier, Bron, France
- INSERM, U1028; CNRS, UMR5292; Lyon Neuroscience Research Center, Psychiatric Disorders: from Resistance to Response - PSYR2 Team, Lyon, F-69000, France
- University Lyon 1, Villeurbanne, F-69000, France
- Department of Emergency Psychiatry, University Hospital Edouard Herriot, Hospices civils de Lyon, Lyon, France
| | | | - Jérôme Brunelin
- Centre Hospitalier Le Vinatier, Bron, France
- INSERM, U1028; CNRS, UMR5292; Lyon Neuroscience Research Center, Psychiatric Disorders: from Resistance to Response - PSYR2 Team, Lyon, F-69000, France
- University Lyon 1, Villeurbanne, F-69000, France
| | - Edouard Leaune
- Centre Hospitalier Le Vinatier, Bron, France
- INSERM, U1028; CNRS, UMR5292; Lyon Neuroscience Research Center, Psychiatric Disorders: from Resistance to Response - PSYR2 Team, Lyon, F-69000, France
- University Lyon 1, Villeurbanne, F-69000, France
- Institute for Philosophical Research, Lyon 3 University, Lyon, France
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Leaune E, Dealberto MJ, Luck D, Grot S, Zeroug-Vial H, Poulet E, Brunelin J. Ethnic minority position and migrant status as risk factors for psychotic symptoms in the general population: a meta-analysis. Psychol Med 2019; 49:545-558. [PMID: 30178719 DOI: 10.1017/s0033291718002271] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Psychotic symptoms (PS) are experienced by a substantial proportion of the general population. When not reaching a threshold of clinical relevance, these symptoms are defined as psychotic experiences (PEs) and may exist on a continuum with psychotic disorders. Unfavorable socio-environmental conditions, such as ethnic minority position (EMP) and migrant status (MS), may increase the risk of developing PS and PEs. We conducted an electronic systematic review and a meta-analysis assessing the role of EMP and MS for the development and persistence of PS in the general population. Sub-group analyses were performed investigating the influence of ethnic groups, host countries, age, types of PS, and scales. Twenty-four studies met our inclusion criteria. EMP was a relevant risk factor for reporting PS [odds ratio (OR) 1.44, 95% confidence interval (CI) 1.22-1.70) and PEs (OR 1.36, 95% CI 1.16-1.60). The greatest risk was observed in people from the Maghreb and the Middle East ethnic groups in Europe (OR 3.30, 95% CI 2.09-5.21), in Hispanic in the USA (OR 1.98, 95% CI 1.43-2.73), and in the Black populations (OR 1.85, 95% CI 1.39-2.47). We found a significant association between MS and delusional symptoms (OR 1.47, 95% CI 1.33-1.62). We found no association between EMP and persistence of PEs.EMP was associated with increased risk of reporting PS and PEs, and the risk was higher in ethnic groups facing deprivation and discrimination. We found an association between MS and delusional symptoms. These results raise questions about the precise role of socio-environmental factors along the psychosis continuum.
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Affiliation(s)
| | | | - David Luck
- Centre de recherche, Institut Universitaire en Santé Mentale de Montréal,Canada
| | - Stéphanie Grot
- Centre de recherche, Institut Universitaire en Santé Mentale de Montréal,Canada
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Ratana R, Sharifzadeh H, Krishnan J, Pang S. A Comprehensive Review of Computational Methods for Automatic Prediction of Schizophrenia With Insight Into Indigenous Populations. Front Psychiatry 2019; 10:659. [PMID: 31607962 PMCID: PMC6759015 DOI: 10.3389/fpsyt.2019.00659] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 08/15/2019] [Indexed: 01/13/2023] Open
Abstract
Psychiatrists rely on language and speech behavior as one of the main clues in psychiatric diagnosis. Descriptive psychopathology and phenomenology form the basis of a common language used by psychiatrists to describe abnormal mental states. This conventional technique of clinical observation informed early studies on disturbances of thought form, speech, and language observed in psychosis and schizophrenia. These findings resulted in language models that were used as tools in psychosis research that concerned itself with the links between formal thought disorder and language disturbances observed in schizophrenia. The end result was the development of clinical rating scales measuring severity of disturbances in speech, language, and thought form. However, these linguistic measures do not fully capture the richness of human discourse and are time-consuming and subjective when measured against psychometric rating scales. These linguistic measures have not considered the influence of culture on psychopathology. With recent advances in computational sciences, we have seen a re-emergence of novel research using computing methods to analyze free speech for improving prediction and diagnosis of psychosis. Current studies on automated speech analysis examining for semantic incoherence are carried out based on natural language processing and acoustic analysis, which, in some studies, have been combined with machine learning approaches for classification and prediction purposes.
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Affiliation(s)
- Randall Ratana
- School of Computing, Unitec Institute of Technology, Auckland, New Zealand
| | - Hamid Sharifzadeh
- School of Computing, Unitec Institute of Technology, Auckland, New Zealand
| | | | - Shaoning Pang
- School of Computing, Unitec Institute of Technology, Auckland, New Zealand
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Pignon B, Amad A, Pelissolo A, Fovet T, Thomas P, Vaiva G, Roelandt JL, Benradia I, Rolland B, Geoffroy PA. Increased prevalence of anxiety disorders in third-generation migrants in comparison to natives and to first-generation migrants. J Psychiatr Res 2018; 102:38-43. [PMID: 29597072 DOI: 10.1016/j.jpsychires.2018.03.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 02/26/2018] [Accepted: 03/19/2018] [Indexed: 12/20/2022]
Abstract
INTRODUCTION We sought to examine the prevalence of anxiety disorders associated with migration in the first-, second- and third-generation. METHODS The French Mental Health in the General Population cross-sectional survey interviewed 38,694 individuals using the MINI. The prevalence of lifetime anxiety disorders, and comorbidities was compared between migrants and non-migrants and by generation. All analyses were adjusted for age, sex, and income and education levels. RESULTS In comparison to natives, pooled anxiety disorders were more common among migrants (25.3% vs. 20.7%, OR = 1.24) and among the three studied generations of migrants. Moreover, the prevalence rate of the pooled anxiety disorders was significantly higher in third-generation migrants, in comparison to first-generation (26.7% vs. 22.6%, OR = 1.14). Prevalence rates were higher in migrants for panic disorder (6.6% vs. 5.3%, OR = 1.20), general anxiety disorder (15.0% vs. 12.0%, OR = 1.24), posttraumatic stress disorder (1.0% vs. 0.6%, OR = 1.51), but not for social anxiety disorder. In comparison to natives, migrants with anxiety disorders had higher prevalence rates of suicide attempts (14.0% vs. 12.8% for natives), psychotic disorders (8.3% vs. 5.7%), unipolar depressive disorder (29.5% vs. 25.4%), bipolar disorder (5.0% vs. 4.0%), and addictive disorders (9.6% vs. 6.2% for alcohol use disorder, 8.2% vs. 4.1% for substance use disorders). CONCLUSION Migration was associated with a higher prevalence of all anxiety disorders, in the first, second and third generation, and associated with more psychiatric comorbidities. Moreover, the prevalence increased across generations, and was significantly higher among third-generation migrants, in comparison to first-generation.
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Affiliation(s)
- Baptiste Pignon
- AP-HP, DHU PePSY, Hôpitaux universitaires Henri-Mondor, Pôle de Psychiatrie, Inserm, U955, Team 15, UPEC, Université Paris-Est, Faculté de médecine, Créteil, 94000, France; Fondation FondaMental, Créteil, 94000, France.
| | - Ali Amad
- Univ. Lille, CNRS UMR 9193-PsyCHIC-SCALab, CHU Lille, Pôle de Psychiatrie, Unité CURE, F-59000, Lille, France; Fédération régionale de recherche en santé mentale (F2RSM) Nord-Pas-de-Calais, F-59000, Lille, France
| | - Antoine Pelissolo
- AP-HP, DHU PePSY, Hôpitaux universitaires Henri-Mondor, Pôle de Psychiatrie, Inserm, U955, Team 15, UPEC, Université Paris-Est, Faculté de médecine, Créteil, 94000, France; Fondation FondaMental, Créteil, 94000, France
| | - Thomas Fovet
- Univ. Lille, CNRS UMR 9193-PsyCHIC-SCALab, CHU Lille, Pôle de Psychiatrie, Unité CURE, F-59000, Lille, France
| | - Pierre Thomas
- Univ. Lille, CNRS UMR 9193-PsyCHIC-SCALab, CHU Lille, Pôle de Psychiatrie, Unité CURE, F-59000, Lille, France
| | - Guillaume Vaiva
- Univ. Lille, CNRS UMR 9193-PsyCHIC-SCALab, CHU Lille, Pôle de Psychiatrie, Unité CURE, F-59000, Lille, France
| | - Jean-Luc Roelandt
- EPSM Lille Métropole, Centre Collaborateur de l'Organisation Mondiale de la Santé pour la recherche et la formation en santé mentale, Equipe Eceve Inserm UMR 1123, Lille, France
| | - Imane Benradia
- EPSM Lille Métropole, Centre Collaborateur de l'Organisation Mondiale de la Santé pour la recherche et la formation en santé mentale, Equipe Eceve Inserm UMR 1123, Lille, France
| | - Benjamin Rolland
- Service Universitaire d'Addictologie, Pôle UP-MOPHA, CH Le Vinatier, Univ. Lyon, 69500, Bron, France; CRNL Inserm U1028/CNRS UMR5292, CH Le Vinatier, 69678, Bron Cedex, France
| | - Pierre A Geoffroy
- Inserm, U1144, Paris, F-75006, France; Université Paris Diderot, Sorbonne Paris Cité, UMR-S 1144, Paris, F-75013, France; AP-HP, GH Saint-Louis, Lariboisière, F. Widal, Pôle de Psychiatrie et de Médecine Addictologique, 75475, Paris Cedex 10, France; Fondation FondaMental, Créteil, 94000, France
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Abstract
PURPOSE OF REVIEW Arguably, the strongest evidence of an environmental contribution to the cause of psychosis is the increased risk for certain groups of migrants and ethnic minorities. This article summarizes findings published since 2016. RECENT FINDINGS Two studies suggested that migration or minority status are proxies for exposure to an inferior social status. A study from Bologna, Italy, showed that the psychosis risk for internal migrants from Southern Italy was as much increased as that for international migrants. A report from New Zealand reported a higher risk for Maoris than for the remainder of the population.Furthermore, a Danish investigation showed that own-group ethnic density of the neighbourhood at age 15 strongly modified the psychosis risk at adult age. This rules out differential mobility during the prodromal phase as an explanation for the ethnic density effect. Preliminary evidence suggests that the psychotogenic effect of migration may be mediated by elevated dopamine in the striatum. SUMMARY An increasing body of evidence suggests that the higher psychosis risk for certain migrant or ethnic minority groups is due to an inferior social status. Neuroimaging of the dopamine system appears to be a promising avenue for research into pathogenesis.
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DeSilva R, Aggarwal NK, Lewis-Fernández R. The
DSM-5
Cultural Formulation Interview: Bridging Barriers Toward a Clinically Integrated Cultural Assessment in Psychiatry. Psychiatr Ann 2018. [DOI: 10.3928/00485713-20180214-01] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Denzel AD, Harte JM, van den Bergh M, Scherder EJA. Ethnic variations regarding clinical profiles and symptom representation in prisoners with psychotic disorders. BJPsych Open 2018; 4:18-28. [PMID: 29388907 PMCID: PMC6020278 DOI: 10.1192/bjo.2017.3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Black and minority ethnic (BME) groups are known to have higher prevalences of psychotic disorders and are over-represented in western penitentiaries and forensic psychiatric institutions. Research from regular mental healthcare settings suggests that they could show different and more severe psychotic symptoms. Aims To explore ethnic variations in severity of symptomatology of BME and non-BME detainees with psychotic disorders. METHOD In this study, 824 patients with psychotic disorders from seven different ethnic groups, imprisoned in a penitentiary psychiatric centre in the Netherlands, were compared on symptom severity and symptom representation using the BPRS-E clinical interview. Data were analysed by means of a multilevel analysis. RESULTS BME patients with psychotic disorders are over-represented in forensic psychiatry, and symptom profiles of prisoners with psychotic disorders vary by ethnicity. Additionally, severity levels of overall psychopathology differ between ethnic groups: patients with an ethnic majority status show more severe levels of psychopathology compared with BME patients. CONCLUSIONS There are differences in symptom severity and symptom profiles between BME patients and non-BME patients. Disregarding these differences could have an adverse effect on the outcome of the treatment. Possible explanations and clinical impact are discussed. Declaration of interest None.
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Affiliation(s)
- A Dorina Denzel
- Department of Clinical Neuropsychology,VU University,Amsterdam,van der Boechorststraat 1,1081 BT Amsterdam,the Netherlands
| | - Joke M Harte
- Netherlands Institute for the Study of Crime and Law Enforcement,(NSCR);Department of Criminology,VU University Amsterdam,de Boelelaan 1105,Initium (1A-46),1081 HV Amsterdam,the Netherlands
| | - Mattis van den Bergh
- Department of Methodology and Statistics,Tilburg University,P.O. Box 90153,5000 LE Tilburg,the Netherlands
| | - Erik J A Scherder
- Professor,Department of Clinical Neuropsychology,VU University,Amsterdam,van der Boechorststraat 1,1081 BT Amsterdam,the Netherlands
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Groen SPN, Richters A, Laban CJ, Devillé WLJM. Implementation of the Cultural Formulation through a newly developed Brief Cultural Interview: Pilot data from the Netherlands. Transcult Psychiatry 2017; 54:3-22. [PMID: 28157446 DOI: 10.1177/1363461516678342] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Outline for a Cultural Formulation (OCF) has remained underutilized in clinical practice since its publication in the DSM-IV in 1994. In the Netherlands, a Cultural Interview (CI) was developed in 2002 as a tool to facilitate use of the OCF in clinical practice. The time needed to conduct the interview, however, prevented its systematic implementation within mental health institutions. This article presents the development of a shortened and adapted version, the Brief Cultural Interview (BCI), and a pilot study on the feasibility, acceptability, and utility of its implementation with refugee and asylum seeking patients in a Dutch centre for transcultural psychiatry. Results show that the brief version scores better on feasibility and acceptability, while utility for clinical practice remains similar to that of the original CI. These results support the systematic use of the OCF in psychiatric care for a culturally diverse patient population through the application of a relatively brief cultural interview. A secondary finding of the study is that patients' cultural identity was considered by clinicians to be more relevant in the treatment planning sessions than their illness explanations.
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Affiliation(s)
| | | | | | - Walter L J M Devillé
- University of Amsterdam, Social Sciences National Knowledge and Advisory Centre on Migrants, Refugees and Health (Pharos) University Medical Center Utrecht, Julius Global Health
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Muralidharan A, Schaffner RM, Hack S, Jahn DR, Peeples AD, Lucksted A. “I Got to Voice What’s in My Heart”: Participation in the Cultural Formulation Interview—Perspectives of Consumers with Psychotic Disorders. ACTA ACUST UNITED AC 2017. [DOI: 10.1007/s40737-017-0076-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zandi T, Havenaar JM, Laan W, Kahn RS, Brink WVD. Effects of a culturally sensitive assessment on symptom profiles in native Dutch and Moroccan patients with a first psychosis referral. Transcult Psychiatry 2016; 53:45-59. [PMID: 25851336 DOI: 10.1177/1363461515577288] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Previous studies have reported a higher incidence of psychosis in Moroccan immigrants in the Netherlands than among native-born residents. However, this disparity was substantially attenuated when cultural differences in symptom presentation were taken into account. To better understand the impact of different diagnostic procedures on incidence rates, we examined the effects of the use of a culturally sensitive diagnostic interview, compared to a standard semi-structured diagnostic interview, on symptom profiles among Moroccan immigrant and native Dutch patients in the Netherlands. A total of 26 Dutch and 26 Moroccan patients referred with a possible first psychosis diagnosis were interviewed twice: once with the standard version and once with a culturally adapted version of the Comprehensive Assessment of Symptoms and History questionnaire (CASH and CASH-CS, respectively). Among native Dutch patients, symptoms profiles based on CASH and CASH-CS interviews were very similar. By contrast, among Moroccan immigrant patients, symptom profiles based on CASH and CASH-CS interviews differed substantially, with more mania symptoms (+30%; p < .05) and fewer delusions (-31%; p < .05) reported when using the CASH-CS. These results suggest that the over-diagnosis of schizophrenia in Moroccan immigrants with a first psychosis referral may be related to a tendency to under-detect mood symptoms and over-detect positive psychotic symptoms when a standard diagnostic procedure is used. This bias may be corrected, at least in part, by the use of a culturally sensitive interview instrument such as the CASH- CS.
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Bäärnhielm S, Åberg Wistedt A, Rosso MS. Revising psychiatric diagnostic categorisation of immigrant patients after using the Cultural Formulation in DSM-IV. Transcult Psychiatry 2015; 52:287-310. [PMID: 25492265 DOI: 10.1177/1363461514560657] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study evaluated the use of the Outline for Cultural Formulation (OCF) from the DSM-IV in the diagnosis of immigrants and refugee patients at an outpatient psychiatric clinic in Sweden. Using the OCF in conjunction with standard diagnostic procedures led to major revisions of diagnoses for 56.5% of patients. Anxiety disorders, especially PTSD, constitute the disorder group in which the most changes were made. In order to understand how information from the OCF interview led clinicians to revise diagnoses, data from clinical discussions were analysed through qualitative content analysis. This revealed four major themes related to the reevaluation, and at times confirmation, of given clinical psychiatric diagnoses: new information; expression of distress in emotional language; expression of distress in relation to life experiences; and improved understanding of the patient's suffering. The findings suggest that the OCF may be useful for: (a) formulating culture in relation to illness experiences, (b) contextualising diagnostic categorisation, and (c) improving overall understanding of the patient that may facilitate individualised planning of treatment and therapy.
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Affiliation(s)
- Sofie Bäärnhielm
- Transcultural Centre, Stockholm County CouncilKarolinska Insitutet
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Lacasse JJ, Forgeard MJC, Jayawickreme N, Jayawickreme E. The factor structure of the CES-D in a sample of Rwandan genocide survivors. Soc Psychiatry Psychiatr Epidemiol 2014; 49:459-65. [PMID: 24173407 DOI: 10.1007/s00127-013-0766-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Accepted: 09/17/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Past research suggests that culture shapes the way psychopathology is experienced and expressed. Standard psychiatric assessment instruments may therefore not capture the same underlying constructs in different contexts. The present study investigated the factor structure of a standard depression scale in a sample of Rwandan genocide survivors. METHODS One hundred ninety six Rwandan adults provided socio-demographic information and completed the Center for Epidemiological Studies-Depression scale (CES-D), one of the most widely used self-report instruments assessing depressive symptoms, as part of a larger study on well-being and mental health in Rwanda. RESULTS A two-factor solution provided the best fit for these CES-D data. The first factor corresponded to general depressive symptoms (including depressed affect, somatic symptoms, and interpersonal concerns) and explained 37.20% of the variance. The second factor included items assessing positive affect and explained 8.68% of the variance. CONCLUSIONS The two-factor solution found in the present study deviates from the commonly reported four-factor structure, but is consistent with studies showing that depressed affect and somatic symptoms may not be experienced as distinct in certain non-Western and minority cultural groups.
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Affiliation(s)
- Justin J Lacasse
- School of Osteopathic Medicine, University of Medicine and Dentistry of New Jersey, Stratford, USA
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Lewis-Fernández R, Aggarwal NK, Bäärnhielm S, Rohlof H, Kirmayer LJ, Weiss MG, Jadhav S, Hinton L, Alarcón RD, Bhugra D, Groen S, van Dijk R, Qureshi A, Collazos F, Rousseau C, Caballero L, Ramos M, Lu F. Culture and psychiatric evaluation: operationalizing cultural formulation for DSM-5. Psychiatry 2014; 77:130-54. [PMID: 24865197 PMCID: PMC4331051 DOI: 10.1521/psyc.2014.77.2.130] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The Outline for Cultural Formulation (OCF) introduced with DSM-IV provided a framework for clinicians to organize cultural information relevant to diagnostic assessment and treatment planning. However, use of the OCF has been inconsistent, raising questions about the need for guidance on implementation, training, and application in diverse settings. To address this need, DSM-5 introduced a cultural formulation interview (CFI) that operationalizes the process of data collection for the OCF. The CFI includes patient and informant versions and 12 supplementary modules addressing specific domains of the OCF. This article summarizes the literature reviews and analyses of experience with the OCF conducted by the DSM-5 Cross-Cultural Issues Subgroup (DCCIS) that informed the development of the CFI. We review the history and contents of the DSM-IV OCF, its use in training programs, and previous attempts to render it operational through questionnaires, protocols, and semi-structured interview formats. Results of research based on the OCF are discussed. For each domain of the OCF, we summarize findings from the DCCIS that led to content revision and operationalization in the CFI. The conclusion discusses training and implementation issues essential to service delivery.
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Khan A, Yavorsky C, Liechti S, Opler M, Rothman B, DiClemente G, Lucic L, Jovic S, Inada T, Yang L. A rasch model to test the cross-cultural validity in the positive and negative syndrome scale (PANSS) across six geo-cultural groups. BMC Psychol 2013; 1:5. [PMID: 25566357 PMCID: PMC4270028 DOI: 10.1186/2050-7283-1-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 02/14/2013] [Indexed: 11/30/2022] Open
Abstract
Background The objective of this study was to examine the cross-cultural
differences of the PANSS across six geo-cultural regions. The specific
aims are (1) to examine measurement properties of the PANSS; and (2) to
examine how each of the 30 items function across geo-cultural
regions. Methods Data was obtained for 1,169 raters from 6 different regions: Eastern
Asia (n = 202), India (n = 185), Northern Europe (n = 126), Russia &
Ukraine (n = 197), Southern Europe (n = 162), United States (n = 297). A
principle components analysis assessed unidimensionality of the
subscales. Rasch rating scale analysis examined cross-cultural
differences among each item of the PANSS. Results Lower item values reflects items in which raters often showed less
variation in the scores; higher item values reflects items with more
variation in the scores. Positive Subscale: Most regions found item P5
(Excitement) to be the most difficult item to score. Items varied in
severity from −0.93 [item P6. Suspiciousness/persecution (USA) to 0.69
item P4. Excitement (Eastern Asia)]. Item P3 (Hallucinatory Behavior) was
the easiest item to score for all geographical regions. Negative
Subscale: The most difficult item to score for all regions is N7
(Stereotyped Thinking) with India showing the most difficulty Δ = 0.69,
and Northern Europe and the United States showing the least difficulty Δ
= 0.21, each. The second most difficult item for raters to score was N1
(Blunted Affect) for most countries including Southern Europe (Δ = 0.30),
Eastern Asia (Δ = 0.28), Russia & Ukraine (Δ = 0.22) and India (Δ =
0.10). General Psychopathology: The most difficult item for raters to
score for all regions is G4 (Tension) with difficulty levels ranging from
Δ = 1.38 (India) to Δ = 0.72. Conclusions There were significant differences in response to a number of items on
the PANSS, possibly caused by a lack of equivalence between the original
and translated versions, cultural differences among interpretation of
items or scoring parameters. Knowing which items are problematic for
various cultures can help guide PANSS training and make training
specialized for specific geographical regions.
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Affiliation(s)
- Anzalee Khan
- ProPhase, LLC, New York, NY United States of America ; Nathan S. Kline Institute for Psychiatric Research, Orangeburg, NY United States of America ; Manahttan Psychiatric Center, Wards Island, NY United States of America
| | - Christian Yavorsky
- ProPhase, LLC, New York, NY United States of America ; CROnos Clinical Consulting Services, Hamilton, NJ United States of America
| | - Stacy Liechti
- The PANSS Research Institute, Inc, New York, NY United States of America
| | - Mark Opler
- ProPhase, LLC, New York, NY United States of America ; New York University, School of Medicine, New York, NY United States of America
| | - Brian Rothman
- ProPhase, LLC, New York, NY United States of America
| | | | - Luka Lucic
- ProPhase, LLC, New York, NY United States of America ; Pratt Institute, Brooklyn, NY United States of America
| | - Sofija Jovic
- ProPhase, LLC, New York, NY United States of America
| | - Toshiya Inada
- Institute of Neuropsychiatry, Seiwa Hospital, Shinjuku-ku, Tokyo, Japan
| | - Lawrence Yang
- ProPhase, LLC, New York, NY United States of America ; Department of Epidemiology, Columbia University, New York, NY United States of America
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Ethnic differences in risk of acute compulsory admission in Amsterdam, 1996-2005. Soc Psychiatry Psychiatr Epidemiol 2012; 47:111-8. [PMID: 21076912 DOI: 10.1007/s00127-010-0312-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 10/18/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE Several European studies have shown that migrants from non-western countries are at increased risk of psychotic disorders. This study examines how this is reflected in the risk of acute compulsory admission (ACA). METHODS Information on all patients with an ACA in Amsterdam from 1996 to 2005 was linked to the Amsterdam municipal register. RESULTS The incidence of first ACA in Amsterdam was 4.5 per 10,000 person years. The incidence risk of ACA for any psychiatric disorders and for psychotic disorders in particular showed a 2- to 3-fold increase in almost all migrant groups from non-western countries, and especially for second-generation migrants. In addition, all non-western migrant groups were at increased risk of being assessed as posing a danger to others. CONCLUSIONS The relative risk of ACA for psychotic disorders was similar to that for the incidence of psychotic disorders in most ethnic groups from other studies, suggesting that the increased risk of ACA in non-western migrants can mainly be explained by the increased incidence of psychotic disorders in these groups. However, the relative risk of ACA for psychotic disorders among Moroccan migrants was lower than expected on the basis of incidence studies, which suggests that additional factors are relevant, such as illness-related expression and access to and quality of care.
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Zandi T, Havenaar JM, Laan W, Kahn RS, van den Brink W. Predictive validity of a culturally informed diagnosis of schizophrenia: a 30 month follow-up study with first episode psychosis. Schizophr Res 2011; 133:29-35. [PMID: 22019074 DOI: 10.1016/j.schres.2011.09.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 09/14/2011] [Accepted: 09/18/2011] [Indexed: 11/29/2022]
Abstract
UNLABELLED Previous research has shown discrepancies between a standard diagnostic interview for schizophrenia (CASH) and a culture sensitive version of this instrument (CASH-CS) in Moroccan patients. More specifically we showed that among Moroccan immigrants the CASH-CS resulted in fewer patients with a diagnosis of schizophrenia compared with diagnoses based on the CASH, whereas for Native Dutch patients there was no difference between the CASH and the CASH-CS. The aim of the current study was to compare the predictive validity of a diagnosis of schizophrenia according to the CASH and CASH-CS. METHOD Thirty months after referral, 26 Moroccan and 26 native Dutch patients with a suspected first psychotic episode were compared with regard to 30-month diagnostic stability, symptom development, psychosocial functioning, medication use and hospitalization using baseline diagnoses based on the two versions of the CASH. RESULTS Moroccan patients who were diagnosed with schizophrenia using the standard CASH at baseline had a significantly better 30-month prognosis than native Dutch patients with the same CASH diagnosis. Prognosis of schizophrenia according to the CASH-CS was similar for Moroccans and native Dutch patients. Diagnostic stability according to the CASH was high for native Dutch (92%), but low for Moroccan patients (27%), whereas diagnostic stability according to the CASH-CS was high for both groups (85% and 81%, respectively). CONCLUSION These data raise questions regarding the validity of the standard CASH in Moroccan immigrants in The Netherlands and support the validity of the CASH-CS. As a consequence, there are serious doubts about the validity of previous studies showing an increased incidence of schizophrenia in immigrants using standard diagnostic procedures.
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Affiliation(s)
- Tekleh Zandi
- Altrecht, Institute for Mental Health Care, Utrecht, The Netherlands.
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Durbin A, Lin E, Taylor L, Callaghan RC. First-generation immigrants and hospital admission rates for psychosis and affective disorders: an ecological study in Ontario. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2011; 56:418-26. [PMID: 21835105 DOI: 10.1177/070674371105600705] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The immigrant population in Canada, and particularly in Ontario, is increasing. Our ecological study first assessed if there was an association between areas with proportions of first-generation immigrations and admissions rates for psychotic and affective disorders. Second, this study examined if area-level risks would persist after controlling for area socioeconomic factors in census-derived geographical areas-Forward Sortation Areas (FSAs)-in Ontario. METHODS Ontario's inpatient admission records from 1996 to 2005 and census data from 2001 were analyzed to derive FSA rates of first admissions for psychotic disorders and affective disorders per 100 000 person-years. Negative binomial regression models were adjusted, first, for FSA age and sex and, second, also for FSA population density and average income. RESULTS Using age- and sex-adjusted models, admission rates for psychotic disorders were higher in areas with greater proportions of immigrants. These areas were associated with lower admission rates for affective disorders. When FSA average income and population density were added to the models, the influence of immigrants was attenuated to nonsignificant levels in models predicting psychotic disorders admission rates. However, greater proportions of immigrants remained significantly protective when predicting rates of affective disorders. DISCUSSION Our study provides insight about the influence of area-level variables on risk of admission for psychotic and affective disorders in high immigrant areas. There is a dearth of current Canadian research on immigrant admission for psychotic disorders at the individual or area level. Future area- and individual-level studies may better identify groups at risk and possible explanations.
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Affiliation(s)
- Anna Durbin
- Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada.
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Abstract
The incidence of psychotic disorders is extremely high in several immigrant groups in Europe. This article describes the epidemiological evidence for increased incidence rates among immigrants compared with nonimmigrant populations and explores possible explanations for this excess risk. Potential causes not only involve factors acting at the level of the individual, but encompass the broader social context of neighborhoods and ethnic groups. Growing up and living in a disadvantaged ethnic minority position, characterized by a low social status, high degree of discrimination against the group and low neighborhood ethnic density, may lead to an increased risk of psychotic disorders, especially when individuals reject their minority status and when their social resources are insufficient to buffer the impact of adverse social experiences. Future research should refine measures of the social context, adopt a life-course perspective and should integrate social and neurobiological pathways.
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Affiliation(s)
- Wim Veling
- Center for Early Psychosis, Parnassia Psychiatric Institute, The Hague, The Netherlands
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Jarvis GE, Toniolo I, Ryder AG, Sessa F, Cremonese C. High rates of psychosis for black inpatients in Padua and Montreal: different contexts, similar findings. Soc Psychiatry Psychiatr Epidemiol 2011; 46:247-53. [PMID: 20165832 DOI: 10.1007/s00127-010-0187-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 01/15/2010] [Indexed: 01/25/2023]
Abstract
OBJECTIVE This study tested the hypothesis that despite differences in setting, specifically in Padua or Montreal, black psychiatric inpatients will have higher rates of assigned diagnosis of psychosis than their non-black counterparts. METHODS Data on psychotic patients admitted to the psychiatry ward were extracted from records of general hospitals in Padua and Montreal. Logistic regression analyses were conducted separately for each site to determine the relation between being black and receiving a diagnosis of psychosis, while controlling for sex and age. RESULTS Most black patients at both sites received a diagnosis of psychosis (76% in Padua and 81% in Montreal). Being black was independently and positively associated with being diagnosed with psychosis compared to patients from other groups. CONCLUSIONS Black patients admitted to psychiatry, whether in Padua or Montreal, were more likely to be assigned a diagnosis of psychosis than were other patients.
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Ierago L, Malsol C, Singeo T, Kishigawa Y, Blailes F, Ord L, Florsheim P, Phillips L, Kuartei S, Tiobech J, Watson B, Ngiralmau H. Adoption, family relations and psychotic symptoms among Palauan adolescents who are genetically at risk for developing schizophrenia. Soc Psychiatry Psychiatr Epidemiol 2010; 45:1105-14. [PMID: 19885633 DOI: 10.1007/s00127-009-0154-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Accepted: 10/01/2009] [Indexed: 11/28/2022]
Abstract
PURPOSE This paper focuses on the role of adoption and family relations as moderators of genetic risk for psychotic disorders. METHODS Participants included 184 adolescents in the Republic of Palau identified to be at genetic risk for schizophrenia and other psychotic disorders. Palau is an island nation in Micronesia with a lifetime prevalence of 1.99% for schizophrenia and 2.67% for psychotic disorders more broadly defined. In Palauan culture, kinship adoption is a common cultural practice; 47 of the 184 participants had been adopted at an early age. The current study was designed to test the hypothesis that adoption would function as a protective factor among Palauan youth at genetic risk for the development of psychotic symptoms. Participants were evaluated for psychotic and other psychiatric symptoms using KSADS-PL. Concurrently, the Youth Self Report was used to assess the perceived quality of family relationships. RESULTS Results indicated that adopted adolescents were more likely to develop psychotic symptoms than non-adopted adolescents. However, perceived family relations moderated the association between adoption status and psychotic symptoms, such that adopted adolescents with poorer family relations reported disproportionately higher rates of psychotic symptoms. Family relations also moderated the association between level of genetic risk and psychotic symptoms, independently of adoption status. CONCLUSION Consistent with previous research, adolescents at high genetic risk who reported more positive family relations also reported fewer psychotic symptoms.
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Affiliation(s)
- Laura Ierago
- Palau Youth Project, Ministry of Health, P. O. Box 6027, Koror 96940, Palau
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Zandi T, Havenaar JM, Smits M, Limburg-Okken AG, van Es H, Cahn W, Algra A, Kahn RS, van den Brink W. First contact incidence of psychotic disorders among native Dutch and Moroccan immigrants in the Netherlands: influence of diagnostic bias. Schizophr Res 2010; 119:27-33. [PMID: 20332065 DOI: 10.1016/j.schres.2010.02.1059] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Revised: 01/20/2010] [Accepted: 02/19/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Several studies have reported increased incidence rates of psychotic disorders among immigrant groups. Surprisingly, the cross-cultural validity of the diagnostic instruments that were used was never tested. AIMS To examine whether the incidence rates of psychotic disorders including schizophrenia among Moroccan immigrants to the Netherlands remain increased when a cultural sensitive diagnostic interview is used. METHOD We compared first contact incidence with a standard and a cultural sensitive version of a diagnostic interview. RESULTS Age and gender adjusted relative risk for psychotic disorders and schizophrenia among Moroccans compared to native Dutch was 7.9 (95% CI 4.7-13.5) and 7.8 (95% CI 4.0-15.2) respectively based on the standard diagnostic interview and 4.2 (95% CI 2.3-7.9) and 1.5 (0.5-4.3) respectively based on the cultural sensitive version the diagnostic interview. CONCLUSION First contact incidence of schizophrenia among Moroccans was no longer significantly higher than among ethnic Dutch people when a cultural sensitive diagnostic procedure was applied.
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Affiliation(s)
- T Zandi
- Altrecht, Institute for Mental Health Care, Utrecht, The Netherlands.
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Betancourt TS, Bass J, Borisova I, Neugebauer R, Speelman L, Onyango G, Bolton P. Assessing local instrument reliability and validity: a field-based example from northern Uganda. Soc Psychiatry Psychiatr Epidemiol 2009; 44:685-92. [PMID: 19165403 PMCID: PMC2716434 DOI: 10.1007/s00127-008-0475-1] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Revised: 11/09/2008] [Indexed: 10/21/2022]
Abstract
This paper presents an approach for evaluating the reliability and validity of mental health measures in non-Western field settings. We describe this approach using the example of our development of the Acholi psychosocial assessment instrument (APAI), which is designed to assess depression-like (two tam, par and kumu), anxiety-like (ma lwor) and conduct problems (kwo maraco) among war-affected adolescents in northern Uganda. To examine the criterion validity of this measure in the absence of a traditional gold standard, we derived local syndrome terms from qualitative data and used self reports of these syndromes by indigenous people as a reference point for determining caseness. Reliability was examined using standard test-retest and inter-rater methods. Each of the subscale scores for the depression-like syndromes exhibited strong internal reliability ranging from alpha = 0.84-0.87. Internal reliability was good for anxiety (0.70), conduct problems (0.83), and the pro-social attitudes and behaviors (0.70) subscales. Combined inter-rater reliability and test-retest reliability were good for most subscales except for the conduct problem scale and prosocial scales. The pattern of significant mean differences in the corresponding APAI problem scale score between self-reported cases vs. noncases on local syndrome terms was confirmed in the data for all of the three depression-like syndromes, but not for the anxiety-like syndrome ma lwor or the conduct problem kwo maraco.
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Affiliation(s)
- Theresa S Betancourt
- Dept. of Population and International Health, François-Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health, Boston, MA 02115, USA.
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Selten JP, Hoek HW. Does misdiagnosis explain the schizophrenia epidemic among immigrants from developing countries to Western Europe? Soc Psychiatry Psychiatr Epidemiol 2008; 43:937-9. [PMID: 18587677 DOI: 10.1007/s00127-008-0390-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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