The DSM-IV Outline for Cultural Formulation: a critical demonstration with American Indian children

Examining the effectiveness of the Cultural Formulation Interview with young children: A clinical illustration

After years of extensive research, the Cultural Formulation Interview (CFI) was released in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Similar to its predecessor, the Outline of the Cultural Formulation (OCF), the CFI aims to refine the psychiatric assessment process by systematically examining cultural factors. However, in contrast to the OCF which employs open-ended questions, the CFI uses a semi-structured interview format. Unfortunately, children and adolescents have only been included in a handful of OCF and CFI studies, which raises questions about their applicability with youth, particularly young children (11 years or younger). In this article, we start examining the usefulness of the CFI with young children and propose recommendations to enhance its benefits by suggesting the development of a supplementary module specifically designed for young children. These ideas are illustrated with the assessment of a 6-year-old boy of Somali descent.

Culture and psychiatric evaluation: operationalizing cultural formulation for DSM-5

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.

One size does not fit all: taking diversity, culture and context seriously

Evidence suggests that the current mental health system is failing in the provision of quality mental health care for diverse children and families. This paper discusses one critical domain missing to improve care: serious attention given to diversity, culture, and context. It discusses what we mean by understanding culture and context at the individual, family, organizational, and societal level. Focusing on key predictors of children's adjustment in natural contexts would increase attention to building community and family capacities that strengthen children's mental health. To conclude, we suggest changes in organizational culture to build natural supports to enhance children's mental health.

Child and adolescent mental disorders: the magnitude of the problem across the globe

OBJECTIVE

Describe objectively the global gaps in policy, data gathering capacity, and resources to develop and implement services to support child mental health.

METHODS

Report on the World health Organization (WHO) child and adolescent mental health resources Atlas project. The Atlas project utilized key informants and was supplemented by studies that focused on policy. This report also draws on current epidemiological studies to provide a context for understanding the magnitude of the clinical problem.

RESULTS

Current global epidemiological data consistently reports that up to 20% of children and adolescents suffer from a disabling mental illness; that suicide is the third leading cause of death among adolescents; and that up to 50% of all adult mental disorders have their onset in adolescence. While epidemiological data appears relatively uniform globally, the same is not true for policy and resources for care. The gaps in resources for child mental health can be categorized as follows: economic, manpower, training, services and policy. Key findings from the Atlas project include: lack of program development in low income countries; lack of any policy in low income countries and absent specific comprehensive policy in both low and high income countries; lack of data gathering capacity including that for country-level epidemiology and services outcomes; failure to provide social services in low income countries; lack of a continuum of care; and universal barriers to access. Further, the Atlas findings underscored the need for a critical analysis of the 'burden of disease' as it relates to the context of child and adolescent mental disorders, and the importance of defining the degree of 'impairment' of specific disorders in different cultures.

CONCLUSIONS

The recent finding of substantial gaps in resources for child mental health underscores the need for enhanced data gathering, refinement of the economic argument for care, and need for innovative training approaches.

Nightmare disorder, dream anxiety, and subjective sleep quality in patients with borderline personality disorder

AIMS

The aims of the present study were to examine the rate of nightmare disorder (ND) and to determine the levels of dream anxiety and subjective sleep quality in patients with borderline personality disorder (BPD). Another aim was to determine whether dream anxiety was associated with childhood trauma, dissociative experiences, and subjective sleep disturbance in BPD patients. Finally, the hypothesis as to whether BPD patients with ND exhibited a more severe clinical profile than those without ND, was also tested.

METHODS

A total of 88 borderline patients and 100 age- and sex-matched healthy control subjects were assessed using the Structured Clinical Interview for DSM-III-R Personality Disorders, Structured Clinical Interview for DSM-IV Axis I Disorders, Van Dream Anxiety Scale, Pittsburgh Sleep Quality Index, Dissociative Experiences Scale, and Traumatic Experiences Checklist. Subjects with codiagnoses that could affect sleep were not included.

RESULTS

BPD patients suffered a significantly greater rate of nightmares, elevated levels of dream anxiety, and disturbed sleep quality than did controls. In the borderline group, heightened dream anxiety was correlated with higher rates of early traumatic experiences and dissociative symptoms, and impaired sleep quality. Furthermore, borderline patients with ND exhibited greater psychopathology as compared to those without ND in terms of several clinical characteristics.

CONCLUSIONS

The present study provides support for a strong association between BPD, distressing nightmares, and subjective sleep quality. Recognition and management of dream and sleep disturbances in BPD patients might lead to improvements in their global clinical picture.

Adverse childhood experiences associated with sleep in primary insomnia

The objectives were to explore the association between self-reported adverse childhood experiences (ACE) and sleep in adults suffering from primary insomnia and to examine the impact of presleep stress on this relationship. Fifty-nine patients with primary insomnia, aged 21-55 years, were administered the Childhood Trauma Questionnaire (CTQ) and then divided into two groups according to the achieved scores: with moderate/severe or low/no reports of ACE. The participants spent three consecutive nights in the sleep laboratory in order to record polysomnographic and actigraphic sleep parameters. A stress induction technique was administered by activating negative autobiographical memories immediately before sleep in the second or third night. Results show that 46% of the insomniac patients reported moderate to severe ACE. This group exhibited a significantly greater number of awakenings and more movement arousals compared to patients with low or no reports of ACE. Actigraphic data also indicated more disturbed sleep and increased nocturnal activity for the high-ACE group. On the other hand, no specific group differences were found with regard to stress condition. The results support the assumption that it is possible to identify a subgroup among patients with primary insomnia who has experienced severe maltreatment in childhood and adolescence. This subgroup appears to differ in several sleep parameters, indicating a more disturbed sleep compared to primary insomniacs with low or no reports of ACE. With regard to sleep-disturbing nightly patterns of arousal, parallels between individuals with high ACE and trauma victims as well as post-traumatic stress disorder-patients suggest themselves.

Perspectives on disparities in depression care

Depression is a major public health problem and a leading cause of disability worldwide. Compounding the high rates of morbidity and mortality and treatment challenges associated with depression are the tremendous disparities in quality of mental health care that exist between the majority of the population and those of racial and ethnic minorities. Although more study data are available on depression care for African Americans than for other groups, racial and ethnic minorities overall are less likely than whites to receive an accurate diagnosis, to receive care according to evidence-based guidelines, and to receive an antidepressant upon diagnosis. Multiple factors contribute to these disparities, among them socioeconomic and cultural issues and prejudices among patients and health care providers. Closing the gap that exists between what depression care is and what depression care could be begins with clinicians' recognizing the relevance of culture to care. Opportunities exist within the broader context of medical education, including continuing medical education (CME), to prepare health care professionals to address the myriad issues related to managing depression.

The case formulation in child and adolescent psychiatry

This article reviews the various definitions of case formulation, differences between diagnosis and case formulation, how case formulation for the child patient differs from the adult patient, and case formulation in the context of residency training, including challenges for residents transitioning from adult psychiatry. It presents a suggested structure for constructing a biopsychosocial formulation that can be applied in a training setting. Several specialized types of psychotherapy formulation are reviewed in more detail. The article concludes with a case example of a child psychiatry resident's case formulation before and after discussion in supervision.

Marital Conflict and Disruption of Children's Sleep

Marital conflict was examined as a predictor of the quality and quantity of sleep in a sample of healthy 8- to 9-year-olds. Parents and children reported on marital conflict, the quantity and quality of children's sleep were examined through an actigraph worn for 7 consecutive nights, and child sleepiness was derived from child and mother reports. Increased marital conflict was associated with disruptions in the quantity and quality of children's sleep as well as subjective sleepiness, even after controlling for child age, ethnic group membership, socioeconomic status, sex, and body mass index. The results support the sensitization hypothesis in that exposure to marital conflict may influence an important facet of children's biological regulation, namely sleep.

Stigma of mental illness among American Indian and Alaska Native nations: historical and contemporary perspectives

Among American Indian and Alaska Native (AIAN) people, the concept of mental illness has different meanings and is interpreted in various ways. This paper describes the realities of mental health care that confront AIAN people. Stigma is associated with mental illness, which can be a barrier for those individuals who are in need of mental health services. Within the context of the AIAN historical and contemporary experiences, the paper details domains that negatively influence the lives of AIAN people. Included are the failure of the U.S. government to fulfill its treaty agreements with AIAN people; the disparities in income and education, and the pervasiveness of poverty; and access to care issues. These domains help to set the stage for health disparities that frequently catapult AIAN people to early morbidity and mortality. Importantly, many of these conditions are preventable. The paper concludes with recommendations for a more diverse workforce that will include AIAN mental health professionals who are available to provide culturally competent care to AIAN people in a variety of settings.

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.

Commentary: quality of alcohol, drug, and mental health services for American Indian children and adolescents

American Indian children and adolescents suffer from a high prevalence of alcohol, drug, and mental (ADM) disorders. Unfortunately, the systems of services for these children and youth have never been able to address adequately their mental health needs. Thus, the revolutionary changes now taking place within these service systems, in particular the marked increase in the direct provision of services by Indian tribes and organizations, provides a unique opportunity to address these historical shortcomings. In this paper, we describe our existing knowledge concerning the quality of ADM services for American Indian children and adolescents and their critical sociodemographic, sociocultural, and epidemiologic contexts. We then consider the implications of these studies for improving the quality of care as well as its measurement and monitoring.