Race bias, social class bias, and gender bias in clinical judgment

Depressive symptomatology from a network perspective: Differences in the experience of symptoms involved in the self-recognition of depression and the diagnosis process by social position

BACKGROUND

While social disparities in depression are well-documented, the symptom experience across social positions remains less studied.

AIMS

This study examines the connections between depressive symptoms and self-recognizing a depressive episode, on the one hand, and clinical diagnosis, on the other hand, by three social position indicators.

METHODS

We analyzed baseline data from a population-based cohort of adults living in France, grouping participants by three indicators: education, financial difficulties, and occupation, and stratifying by sex. Utilizing a psychometric network approach, we estimated 24 networks. Nodes corresponded to the 20 CES-D items and 1 external variable, either 'Limitations due to depression' or 'Clinical depression'. Comparisons between socially disadvantaged and advantaged groups across the three social indicators were made in terms of network structures, global strength, and edge weights involving symptoms and both external nodes.

RESULTS

The study included data from 201,952 participants. Individuals in lower social positions exhibited higher rates of depressive-related variables. Four depressive symptoms emerged as crucial, being linked both to 'Clinical depression' and 'Limitations' across all social positions. Socially disadvantaged groups had denser networks. Some of the tests comparing network structures according to social position were significant, suggesting differences in the symptom activation chains. Connections between each external node and 'Felt depressed' and 'Could not get going' were non-invariant in educational and financial-based networks.

CONCLUSIONS

Findings highlight four depressive symptoms, likely to play a key role in the experience of depression across all social positions. Other insights from specific symptoms could be used for improving depression care among disadvantaged populations.

Evidence-Based Assessment of DSM-5 Disruptive, Impulse Control, and Conduct Disorders

The assessment of oppositional defiant disorder, conduct disorder, antisocial personality disorder, and intermittent explosive disorder-the Disruptive, Impulse Control and Conduct Disorders-can be affected by biases in clinical judgment, including overestimating concerns about distinguishing symptoms from normative behavior and stigma associated with diagnosing antisocial behavior. Recent nosological changes call for special attention during assessment to symptom dimensions of limited prosocial emotions and chronic irritability. The present review summarizes best practices for evidence-based assessment of these disorders and discusses tools to identify their symptoms. Despite the focus on disruptive behavior disorders, their high degree of overlap with disruptive mood dysregulation disorder can complicate assessment. Thus, the latter disorder is also included for discussion here. Good practice in the assessment of disruptive behavior disorders involves using several means of information gathering (e.g., clinical interview, standardized rating scales or checklists), ideally via multiple informants (e.g., parent-, teacher-, and self-report). A commitment to providing a full and accurate diagnostic assessment, with careful and attentive reference to diagnostic guidelines, will mitigate concerns regarding biases.

Beyond recovery: toward rights-based mental health care - A cluster randomized wait-list controlled trial of a recovery and rights training for mental health professionals with or without first person accounts

Introduction

Mental health models grounded in Recovery and Rights are driving the advancement of transformative care systems through multifaceted actions, which encompass Continuing Professional Development. The objective of this work is to evaluate a training activity developed through a participatory process that included people with lived experience of psychosocial distress, their relatives, and mental health professionals.

Methods

The training focused on alternatives to diagnosis, recovery principles, rights-based care, and peer support. The evaluation followed a cluster randomized wait-list controlled design. Four hundred eighty-eight health professionals from eight care centers were randomized to three experimental conditions: a wait list control, which underwent a one-month interval between the baseline assessment and the training activity, and two experimental groups, with or without first-person accounts, which accessed the training immediately after completing the baseline assessment. The dependent variables measured at all follow-ups were beliefs and attitudes toward mental health service users' rights. One hundred ninety-two professionals completed at least one follow-up and were included in the analyses.

Results

We observed different evolutions of experimental and control groups with statistically significant differences for tolerance to coercion and total beliefs and attitudes scores. No differences were observed between the groups with or who attended training activities with or without first person accounts. Upon receiving the training activity, the control group had an evolution equivalent to the experimental groups.

Discussion

The results of this evaluation project provide compelling evidence for the need to expand recovery and rights training activities to reach a larger audience of mental health professionals These training activities hold the potential to positively influence the beliefs and attitudes of mental health professionals, ultimately contributing toward a better future for individuals with lived experience of psychosocial distress.

Patient perspectives on pulmonary hypertension in the United States: Burdens, expectations, and goals

Pulmonary hypertension (PH) is a life-threatening, debilitating disease caused by increased blood pressure in the pulmonary arteries. As patients living in the United States, we have unique insights into the journey from diagnosis and treatment within the US healthcare system and the significant impact that PH has on our quality of life. While there have recently been advances in PH management, there are several areas of PH care which we feel should be reassessed and improved. Commonly, diagnosis is lengthy and convoluted due to the rarity of the disease and limited knowledge of PH in primary care. There are also barriers to obtaining the right treatment and we feel that a more holistic approach to care is needed. Mental health is commonly overlooked and should be an integral part of patient care, as should elements such as nutritional advice, cardiopulmonary rehabilitation, and sexual health. PH patient associations play a key role in providing social, educational, and financial support to patients and caregivers alongside PH research and advocacy. As patients, we feel that we need to advocate for correct diagnosis, timely referral, and optimal treatment, in addition to overcoming the financial and/or administrative hurdles to obtain these. We propose several future goals to help empower patients to play an active, central role in their care and to improve all aspects of PH management. We advocate for further use of the patient voice in research and clinical development programs, including the use of patient-reported outcomes that have been developed with patient input.

Socioeconomic status and access to psychotherapy

OBJECTIVE

Individuals with low socioeconomic status (SES) have significantly higher prevalence rates of mental disorders than those with higher SES, but are less likely to receive treatment. Studies from the United States show that individuals with higher SES are more likely to be offered a therapy place than those with low SES. In Germany, where the public health care system is without financial barriers, studies on access to treatment are lacking.

METHOD

The present study investigated whether the SES of persons seeking psychotherapeutic help in Germany influences psychotherapists' decision to provide access to treatment. For this purpose, 504 licensed outpatient psychological psychotherapists participated in an online study, in which they read a series of case vignettes and rated how likely they would be to offer treatment in each case. SES was operationalized by occupation and language use. Additionally, we investigated whether treatment offers were affected by the disorder and the gender of the help seeker, the therapists' socioeconomic background, and other characteristics in interaction with SES. Bonferroni-corrected multifactorial repeated measures analysis of variances (ANOVAs) and mixed ANOVAs were calculated.

RESULTS

Help seekers with low SES were 4.1% less likely to be offered treatment than those with moderate to high SES (F (1, 503) = 115.64; p = 0.000; η² =  0.187). The influence of SES on the probability of a therapy place offer varied significantly depending on the patient's disorder (p = 0.000): SES had a greater effect for bulimia than for depression and social anxiety disorder. Overall, the effect was small (η² = 0.026). No significant interaction between the gender of potential clients and SES was found (p = 0.062). The influence of SES on treatment accessibility varied depending on the therapeutic method for which the therapist was licensed and on the social status of the district in which the therapist's practice was located. The therapist's socioeconomic background (parental SES) did not interact with the potential client's SES.

CONCLUSION

Therapist biases contributing to unequal access to treatment for individuals with low SES and other characteristics can aggravate mental health care disparities. Even though the effects we found were relatively modest, awareness of the association between SES and offers of therapy places might help practitioners to reflect on their own selection practices.

Racial and gender-based disparities and trends in common psychiatric conditions in liver cirrhosis hospitalizations: A ten-year United States study

BACKGROUND

Chronic liver disease is associated with various neuropsychiatric conditions. There are currently no large studies assessing and comparing the prevalence of psychiatric illnesses based on patient profiles and the etiology of cirrhosis.

AIM

To examine the trends of hospitalizations among psychiatric conditions in cirrhosis.

METHODS

We used the National Inpatient Sample database 2009-2019 for the primary diagnosis of liver cirrhosis. The outcomes included the prevalence, trends, and associations of psychiatric diagnoses in these hospitalizations. Chi-square for categorical variables and the Wilcoxon rank test for continuous variables were utilized.

RESULTS

The prevalence of generalized anxiety disorder (GAD) in liver cirrhosis hospitalizations increased from 0.17% in 2009 to 0.92% in 2019 (P < 0.001). The prevalence of depression increased from 7% in 2009 to 12% in 2019 (P < 0.001). Attention deficit hyperactivity disorder (ADHD) prevalence increased from 0.06% to 0.24%. The prevalence of schizophrenia increased from 0.59% to 0.87% (P < 0.001). Schizoaffective disorder prevalence increased from 0.10% to 0.35% (P < 0.001). Post-traumatic stress disorder (PTSD) prevalence displayed increasing trends from 0.36% in 2009 to 0.93% in 2019 (P < 0.001). The prevalence of suicidal ideation increased from 0.23% to 0.56% in 2019. Cirrhosis related to alcoholic liver disease [adjusted odds ratios (aOR) 1.18, 95%CI 1.08-1.29, P < 0.001] and non-alcoholic fatty liver disease (NAFLD) (aOR 1.14, 95%CI 1.01-1.28, P = 0.025) was associated with depression more than other causes. Alcohol- and NAFLD-associated cirrhosis had a stronger link to psychiatric disorders. Females had a higher association with GAD (aOR 2.56, 95%CI 2.14-3.06, P < 0.001), depression (aOR 1.78, 95%CI 1.71-1.84, P < 0.001), bipolar disorder (aOR 1.64, 95%CI 1.52-1.77, P < 0.001] and chronic fatigue (aOR 2.31, 95%CI 1.31-4.07, P < 0.001) when compared to males. Blacks, Hispanics, and Asian/Native Americans had a significantly lower association with GAD, depression, bipolar disorder, PTSD, and ADHD when compared to the white race.

CONCLUSION

The prevalence of psychiatric comorbidities in liver cirrhosis hospitalizations has increased over the last decade. Females had a higher association with psychiatric disorders compared to males. Blacks, Hispanics, and Asian/Native Americans had lower associations with psychiatric comorbidities compared to the white race.

The Nocebo Effect and Informed Consent-Taking Autonomy Seriously

The nocebo effect, a phenomenon whereby learning about the possible side effects of a medical treatment increases the likelihood that one will suffer these side effects, continues to challenge physicians and ethicists. If a physician fully informs her patient as to the potential side effects of a medicine that may produce nocebogenic effects, which is usually conceived of as being a requirement associated with the duty to respect autonomy, she risks increasing the likelihood that her patient will experience these side effects and therefore suffer (unnecessary) harm, a violation of the duty of nonmaleficence. If, on the other hand, she intentionally withholds side effect information in an effort to protect her patient from suffering unnecessary harm from side effects, which is consistent with the duty of nonmaleficence, she violates the duty to respect patient autonomy. In this paper, the author discusses several previous attempts to deal with the nocebo effect and explains their weaknesses. He then proposes a means of managing the nocebo effect and argues that it does not share the weaknesses found in previous approaches. He concludes with a discussion of a simple, yet practical tool that might help clinicians manage the tension resulting from the nocebo effect.

Black Caregivers' Perspectives on Racism in ASD Services: Toward Culturally Responsive ABA Practice

Significant racial and ethnic disparities in health care and service access exist. In the present article, we reviewed qualitative studies investigating the racism-related experiences of Black caregivers of children with autism spectrum disorder (ASD) in the U.S. health care system. Specifically, we examined institutional racism (i.e., systemic racism) and individual racism directed toward Black families when they seek diagnoses and services for their children with ASD. Additionally, we summarized culturally responsive and context-specific practice guidelines to work collaboratively with Black caregivers of children with ASD for applied behavior analysis practitioners.

What People Really Think About Safety around Horses: The Relationship between Risk Perception, Values and Safety Behaviours

The equestrian industry reports high rates of serious injuries, illness and fatalities when compared to other high-risk sports and work environments. To address these ongoing safety concerns, a greater understanding of the relationship between human risk perception, values and safety behaviours is required. This paper presents results from an international survey that explored relationships between a respondents' willingness to take risk during daily activities along with, their perceptions of risk and behaviours during horse-related interactions. Respondents' comments around risk management principles and safety-first inspirations were also analysed. We examined what humans think about hazardous situations or activities and how they managed risk with suitable controls. Analysis identified three important findings. First, safe behaviours around horses were associated with safety training (formal and/or informal). Second, unsafe behaviours around horses were associated with higher levels of equestrian experience as well as income from horse-related work. Finally, findings revealed a general acceptance of danger and imminent injury during horse interactions. This may explain why some respondents de-emphasised or 'talked-down' the importance of safety-first principles. In this paper we predominantly reported quantitative findings of respondents self-reported safety behaviours, general and horse-related risk perceptions despite injury or illness. We discussed the benefits of improved safety-first principles like training, risk assessments, rider-horse match with enriched safety communications to enhance risk-mitigation during human-horse interactions.

Do poor patients suffer from inaccurate diagnoses more than well-to-do patients? A randomized control trial

BACKGROUND

Poor patients have greater morbidity and die up to 10 years earlier than patients who have higher socio-economic status. These findings are often attributed to differences in life-style between groups. The present study aimed at investigating the extent to which physicians contribute to the effect by providing relative poorer care, resulting in relative neglect in terms of time spent with a poor patient and more inaccurate diagnoses.

METHODS

A randomised experiment with 45 internal medicine residents. Doctors diagnosed 12 written clinical vignettes that were exactly the same except for the description of the patients' socio-economic status. Each participant diagnosed four of the vignettes in a poor-patient version, four in a rich-patient version, and four in a version that did not contain socio-economic markers, in a balanced within-subjects incomplete block design. Main measurements were: diagnostic accuracy scores and time spent on diagnosis.

RESULTS

Mean diagnostic accuracy scores (range 0-1) did not significantly differ among the conditions of the experiment (for poor patients: 0.48; for rich patients: 0.52; for patients without socio-economic markers: 0.54; p > 0.05). While confronted with patients not presenting with socio-economic background information, the participants spent significantly less time-to-diagnosis ((for poor patients: 168 s; for rich patients: 176 s; for patients without socio-economic markers: 151 s; p < 0.01), however due to the fact that the former vignettes were shorter.

CONCLUSION

There is no reason to believe that physicians are prejudiced against poor patients and therefore treat them differently from rich patients or patients without discernible socio-economic background.

Migration, ethnicity and psychoses: evidence, models and future directions

There is a large body of research reporting high rates of psychotic disorders among many migrant and minority ethnic groups, particularly in Northern Europe. In the context of increasing migration and consequent cultural diversity in many places worldwide, these findings are a major social and public health concern. In this paper, we take stock of the current state of the art, reviewing evidence on variations in rates of psychoses and putative explanations, including relevant theories and models. We discuss in particular: a) the wide variation in reported rates of psychotic disorders by ethnic group, and b) the evidence implicating social risks to explain this variation, at ecological and individual levels. We go on to set out our proposed socio-developmental model, that posits greater exposure to systemic social risks over the life course, particularly those involving threat, hostility and violence, to explain high rates of psychoses in some migrant and minority ethnic groups. Based on this analysis, the challenge of addressing this social and public health issue needs to be met at multiple levels, including social policy, community initiatives, and mental health service reform.

Predictors of Historical Clinical Risk Management-20 Version 3 (HCR-20:V3) summary risk ratings

How individual risk factors on structured professional judgement (SPJ) assessment tools translate into SPJ final risk formulations is unclear due to a lack of structured criteria. Understanding pathways to risk formulations is vital, as they serve as intervention targets for risk management. This study examined how Historical Clinical Risk Management-20 Version 3 (HCR-20:V3) raters weighed varied information sources to complete summary risk ratings (SRRs). Four independent raters retrospectively coded an archived sample of 32 inpatients at a Canadian forensic psychiatric hospital. HCR-20:V3 SPJ SRRs were regressed on the 20 individual items and sample covariates to identify unique predictors of risk formulations across each rater. Raters consistently used HCR-20:V3 items and composite subscales for SRRs. Despite strong inter-rater agreement on the SRRs, there were variations across raters regarding which items informed each SRR. Rater-unique biases were also shown to influence SRRs. Implications for forensic practice and risk management are discussed.

Determinants and Predictive Value of Clinician Assessment of Short-Term Suicide Risk

We examine the interrelations among clinicians' judgment of patients' suicide risk, clinicians' emotional responses, and standard risk factors in the short-term prediction of suicidal thoughts and behaviors. Psychiatric outpatients (n = 153) with a lifetime history of suicide ideation/attempt and their treating clinicians (n = 67) were evaluated at intake. Clinicians completed a standard suicide risk instrument (modified SAD PERSONS scale), a 10-point Likert scale assessment of judgment of patient suicide risk (Clinician Prediction Scale), and a measure of their emotional responses to the patient (Therapist Response Questionnaire-Suicide Form). The Columbia Suicide Severity Rating Scale and the Beck Scale for Suicide Ideation were administered at a one-month follow-up assessment (n = 114, 74.5%). Clinician judgment of risk significantly predicted suicidal thoughts and behaviors at follow-up. Both the standard suicide risk instrument and clinician emotional responses contributed independently to the clinician assessment of risk, which, in turn, mediated their relationships with suicidal thoughts and behaviors. Our findings validate the importance of clinical judgment in assessing suicide risk. Clinical judgment appears to be informed both by concrete risk factors and clinicians' emotional responses to suicidal patients, highlighting emotional awareness as a promising area for research and training.

An Investigation of Diagnostic Accuracy and Confidence Associated with Diagnostic Checklists as Well as Gender Biases in Relation to Mental Disorders

This study examines the utility of checklists in attaining more accurate diagnoses in the context of diagnostic decision-making for mental disorders. The study also aimed to replicate results from a meta-analysis indicating that there is no association between patients’ gender and misdiagnoses. To this end, 475 psychotherapists were asked to judge three case vignettes describing patients with Major Depressive Disorder (MDD), Generalized Anxiety Disorder, and Borderline Personality Disorder. Therapists were randomly assigned to experimental conditions in a 2 (diagnostic method: with using diagnostic checklists vs. without using diagnostic checklists) × 2 (gender: male vs. female case vignettes) between-subjects design. Multinomial logistic and linear regression analyses were used to examine the association between the usage of diagnostic checklists as well as patients’ gender and diagnostic decisions. The results showed that when checklists were used, fewer incorrect co-morbid diagnoses were made, but clinicians were less likely to diagnose MDD even when the criteria were met. Additionally, checklists improved therapists’ confidence with diagnostic decisions, but were not associated with estimations of patients’ characteristics. As expected, there were no significant associations between gender and diagnostic decisions.

The Role of Environment in Mental Health

Despite substantial progress in developing empirically validated psychotherapeutic treatments for specific mental health problems, most current efforts are based largely on treatment with drugs, which may not produce permanent recovery. The result has been an almost nihilistic attitude that assumes that little can be done to rehabilitate persons with mental health problems. Empirical evidence gleaned from innovative treatment programs and ethnocultural studies indicates clearly that healthy environments that provide meaningful work and a variety of nonmedical interventions offer more lasting health results than medical treatment alone. The supportive and curative influence of the environment has been greatly neglected, in part because of medical dominance in the treatment of emotional problems. More effective is the removal of the social, economic, and professional barriers to mental health and the strengthening of rehabilitative efforts that promote activity and purpose.

A Two-Stage Method for the Study of Cultural Bias in the Diagnosis of Schizophrenia in African Americans

Reasons for diagnostic bias in psychiatric evaluations of African Americans fall into two basic categories: clinician bias, which is the lack of adherence to diagnostic criteria during psychiatric evaluations, and cultural bias, which is true ethnic/racial differences in symptom expression being overlooked or misinterpreted by diagnosticians. The ideal method of studying cultural biases in the psychiatric diagnosis of African Americans is a two-stage procedure with the first stage controlling for clinician bias and the second stage addressing cultural bias. This study evaluated a two-stage procedure that first considers clinician bias by a structured clinical interview followed by a best estimate diagnosis by a mental health clinician who is a cultural expert. The method was developed and evaluated for its reliability and validity in the Culturally Sensitive Diagnostic Interview Research Project. Data from 24 psychiatric inpatients were used to evaluate this diagnostic approach. Several hypotheses were tested, but not all were supported.

Cultural Mistrust and Mental Health Services for African Americans

The underutilization of mental health services by African Americans may be due, in part, to their cultural mistrust. The purpose of this article is twofold: (a) to conduct a meta-analysis of the correlations between cultural mistrust in African Americans and their attitudes and behaviors related to mental health services use, comparing them to the correlations between cultural mistrust and measures relevant to other psychosocial domains, and (b) to test some methodological hypotheses about the Cultural Mistrust Inventory, the most popular measure of cultural mistrust. The meta-analysis suggests that the negative effects of Blacks’ cultural mistrust in interracial situations are not unique to counseling and psychotherapy but represent a broader perspective. The meta-analysis also suggests that development of the Cultural Mistrust Inventory with a male-only college sample did not compromise its external validity. The implications of these results for the provision of mental health services to African Americans are discussed.

Evidence-Based Practice:

A consensus has long existed that the scientist-practitioner model has failed to reflect what was envisioned by the Boulder Conference participants and endorsed by counseling psychology at the Greyston and Georgia Conferences. Counseling psychology's commitment, however, to the scientist-practitioner model has not faltered. Furthermore, developments within the health care system (e.g., managed care, empirically validated treatments, treatment guidelines) demand from psychologists increasing levels of scientific knowledge and a wider range of research skills. Psychology's current commitment to positivist explanation , scientific knowledge characterized by law-governed causal processes, is at the core of the scientist-practitioner split. To integrate scientist-practitioner ideals into a comprehensive approach to counseling psychology training, research, and practice, counseling psychologists should embrace an identity as evidence- based practitioners. Inherent in this framework is a philosophical, scientific, political, and social shift toward an expanded view of what constitutes scientific evidence.

Prevalence and sociodemographic patterns of antidepressant use among women of reproductive age: a prescription database study

BACKGROUND

There has been a steady increase in the prescription of antidepressants in developed countries in recent decades. Antidepressant treatment prevalence and sociodemographic pattern data can inform the review of clinical guidelines for depression treatment. We determined the one-year prevalence and sociodemographic pattern of antidepressant dispensing among women of childbearing age (15-45 years) in Northern Ireland (NI).

METHODS

A cross-sectional study using individual electronic prescribing data for 2009. Our study population was 268,917 women of childbearing age (15-45 years), with/without prescriptions, registered with the 246 out of 363GP practices in NI with high electronic prescribing data coverage. Socioeconomic deprivation (in quintiles) was measured by an area indicator attached to residential postcode.

RESULTS

The one-year prevalence of redeemed antidepressant prescriptions was 16.3% (95% CI 16.1-16.4). More than two-thirds of antidepressant prescriptions were for SSRIs. Thirty-five per cent of the women who redeemed prescriptions for antidepressants also redeemed prescriptions for psycholeptics within 2 months of the antidepressant prescriptions. Redeemed antidepressant prescription prevalence increased from 4.8% (15-19 years) to 24.6% (40-45 years), from 13.5% (quintile 1, least deprived) to 20.7% (quintile 5, most deprived), and with urbanity of GP practice location.

LIMITATION

Only GP practices with high capture of electronic prescribing data were included, which may not be entirely representative of NI. We could not assess the appropriateness of prescribing according to national guidelines.

CONCLUSIONS

Antidepressant use is high among women of childbearing age in NI and increases with age and socioeconomic deprivation. This reinforces the need to address the determinants of depression, and assess the appropriateness of treatment policies and practices.

Racial disparities in psychotic disorder diagnosis: A review of empirical literature

Psychotic disorder diagnoses are common in the United States and internationally. However, racial disparities in rates of psychotic disorder diagnoses have been reported across time and mental health professions. This literature review provides an updated and comprehensive summary of empirical research on race and diagnosis of psychotic disorders spanning a 24-year period. Findings reveal a clear and pervasive pattern wherein African American/Black consumers show a rate of on average three to four higher than Euro-American/White consumers. Latino American/Hispanic consumers were also disproportionately diagnosed with psychotic disorders on average approximately three times higher compared to Euro-American/White consumers. In addition, a trend among international studies suggests that immigrant racial minority consumers receiving mental health services may be assigned a psychotic disorder diagnosis more frequently than native consumers sharing a majority racial background. Potential explanations for this phenomenon are discussed, including possible clinical bias and sociological causes such as differential access to healthcare and willingness to participate in mental health services. Directions for future research should include the exploration of disproportionate diagnoses according to race through qualitative interviewing as well as empirical investigation.

Influence of social class perceptions on attributions among mental health practitioners

OBJECTIVE

A vignette-based study assessed the influence of social class attributions toward a hypothetical client's difficulty.

METHOD

188 licensed mental health professionals who were recruited through professional listservs completed an online survey after reviewing one of two versions of a vignette describing a hypothetical client that varied based on social class cues.

RESULTS

As expected, this sample of licensed mental health practitioners detected social class differences based on the descriptors of the hypothetical client across the two vignettes. These perceived social class differences, however, did not impact participants' attributions toward the client for causing or solving her problems, level of Global Assessment of Functioning score ascribed to the client, or willingness to work with the client.

CONCLUSIONS

There was no evidence that participants differentially ascribed attributions based on social class. Implications and directions for future research are provided.

A qualitative analysis of barriers, challenges, and successes in meeting the needs of Hurricane Katrina evacuee families

Hurricane Katrina caused many individuals to evacuate to towns and cities throughout the United States. Psychological First Aid (PFA) is a treatment program designed to help clinicians and other disaster relief workers address the needs of adults, youth, and families immediately following disasters. We conducted focus groups with disaster relief and evacuee service providers in the Kansas City Metro Area as an exploratory study to identify their perceptions of the needs of evacuees. Participants identified a number of mental health needs, as well as displacement-related challenges, including loss of social support, material loss, unemployment, and other stressful life events that were secondary to the hurricane. Many of these needs are consistent with principles presented in the PFA manual. We also found that service providers faced unique challenges when attempting to assist evacuees. We discuss implications of these findings for treatment programs and provide suggestions for addressing barriers to care.

Toward understanding ethnic and cultural factors in the interviewing process

The clinical interview is critical in the diagnostic assessment undertaking in clinical settings, and cultural/ethnic influences have been shown to influence the outcome of this process. Specifically, a number of studies have reported that proportionally far more ethnic minorities than Caucasians are likely to be misdiagnosed when assessed for psychiatric disorders. This particularly is the case when open clinical interviews are used. Semistructured interviews, on the other hand, result in an increase in diagnostic accuracy with ethnic minorities. Parameters associated with bias in the clinical interview of ethnic minorities and its impact on assessment, diagnosis, and treatment decisions are examined. Although the current discussion focuses primarily on African Americans, many examples are provided that pertain to other ethnic groups. Strategies for addressing these issues are explored and recommendations for increasing cultural competence are made. (PsycINFO Database Record (c) 2011 APA, all rights reserved).

Assessment of moral judgment and empathy in young sex offenders: a comparison of clinical judgment and test results

Professional decision making in forensic clinical practice may have lifelong consequences for offenders. Although information on moral development is important for prediction of reoffending and referral to adequate treatment, conclusions regarding moral development are still largely based on unstructured clinical judgment instead of assessment instruments. For this study, the authors examined to what extent unstructured clinical judgment of both moral judgment and victim empathy concurred with test results in a group of young sex offenders. Moral judgment was measured with the Sociomoral Reflection Measure-Short Form (SRM-SF), whereas victim empathy was measured with an extended version of the Basic Empathy Scale (BES). No significant associations were found between clinical judgment of moral judgment and the mean scores on the SRM-SF. However, clinical judgment of victim empathy was significantly associated with victim empathy on the Victim Empathy Scale but not consistently in the expected direction. Juvenile sex offenders, who were judged by clinicians to show little victim empathy, displayed lower mean scores on the Victim Empathy Scale than juvenile sex offenders who were evaluated to lack victim empathy or to have intact victim empathy. This study showed unstructured clinical judgment of moral development not to concur with test results. To improve decision-making processes regarding moral development, clinicians are advised to rely on instruments that assess moral development to inform clinical judgment. Further research is needed to examine which predictions are more accurate and to establish the predictive validity of moral development evaluations.

Informants are not all equal: predictors and correlates of clinician judgments about caregiver and youth credibility

OBJECTIVE

The objectives of this study were to examine how often clinicians judged youths or caregivers to not be credible informants, to identify the associated features of youth or caregiver credibility, and to examine credibility's impact on the validity of mood and behavior checklists.

BACKGROUND

Clinicians often have the experience of talking to a parent or a youth and judging that the credibility of the information offered is unusually poor. Little is known about the correlates of poor credibility or about the extent to which credibility changes the validity of commonly used checklists.

METHODS

Interviewers rated the credibility of 646 youths aged 5-18 and their primary caregivers after completing a Kiddie Schedule for Affective Disorders and Schizophrenia. Ratings and diagnoses were blind to the behavior checklists completed by caregivers, youths, and teachers. A subset of youths also had intelligent quotient tests and behavioral observations available.

RESULTS

Caregivers were perceived as more credible on average than youths, though this dropped sharply with adolescents. Caregiver credibility was higher for better functioning families, more credible youths, younger youths, and more educated caregivers; it was unrelated to caregiver mood symptoms or being the mother. Youth credibility was strongly connected to age, cognitive ability, caregiver credibility, and independent observations of youth behavior. Credibility ratings markedly altered the validity of checklists compared with interview ratings, diagnoses, or cross-informant criteria.

CONCLUSION

Clinicians' judgments about informant credibility are associated with different characteristics for youths versus caregivers, though youth age is important to both. Credibility affects the validity of information from checklists measured against several different independent criteria.

Implicit and explicit stigma of mental illness: links to clinical care

This study examined implicit and explicit measures of bias toward mental illness among people with different levels of mental health training, and investigated the influence of stigma on clinically-relevant decision-making. Participants (N = 1539) comprised of (1) mental health professionals and clinical graduate students, (2) other health care/social services specialists, (3) undergraduate students, and (4) the general public self-reported their attitudes toward people with mental illness, and completed implicit measures to assess mental illness evaluations that exist outside of awareness or control. In addition, participants predicted patient prognoses and assigned diagnoses after clinical vignettes. Compared with people without mental health training, individuals with mental health training demonstrated more positive implicit and explicit evaluations of people with mental illness. Further, explicit (but not implicit) biases predicted more negative patient prognoses, but implicit (and not explicit) biases predicted over-diagnosis, underscoring the value of using both implicit and explicit measures.

The Meta-Analysis of Clinical Judgment Project

Clinical and educational experience is one of the most commonly studied variables in clinical judgment research. Contrary to clinicians' perceptions, clinical judgment researchers have generally concluded that accuracy does not improve with increased education, training, or clinical experience. In this meta-analysis, the authors synthesized results from 75 clinical judgment studies where the experience of 4,607 clinicians was assessed in relation to the accuracy of their judgments about mental health (e.g., diagnosis, prognosis, treatment) and psychological issues (e.g., vocational, personality). The authors found a small but reliable effect, d = .12, showing that experience, whether educational or clinical, is positively associated with judgment accuracy. This small effect was robust across several tested moderator models, indicating experienced counselors and clinicians acquire, in general, almost a 13% increase in their decision-making accuracy, regardless of other factors. Results are discussed in light of their implications for clinical judgment research and for counseling psychology training and practice.

Toward a Cognitive Process Model of Ethnic/Racial Biases in Clinical Judgment

The purpose of the present article is to discuss approaches to the development of cognitive process models of misdiagnosis of African Americans, with particular emphasis on structured clinical interviews. Two basic approaches to cognitive process models are discussed. The first is cognitive bias based on prototype models of information processing. The second approach involves using the structured clinical interview to see how and when the decision-making process may be flawed, or where cognitive shifts are made in considering one diagnosis over another. Although routine training in structured clinical interviews may nullify cognitive biases associated with clinician judgment, it does not address cultural biases in the diagnostic system. It is concluded that a comprehensive approach to training in clinical decision making for mental health professionals is needed which include courses in the administration of the Structured Clinical Interview for DSM-IV, sociocultural case formulation, and cross-cultural sensitivity in making psychodiagnostic judgments.

Family-focused treatment of the suicidal bipolar patient

OBJECTIVES

Bipolar patients are at high risk for suicidal ideation and attempts. Suicidal behavior is correlated with poor family communication and/or high levels of intrafamilial conflict, particularly among adolescent bipolar patients. This article describes the application of family-focused therapy (FFT) as an adjunct to pharmacotherapy in the management of suicidal ideation and behavior among bipolar patients.

METHODS

We describe the empirical basis of FFT in studies of adult and adolescent patients. We then describe the manner by which the three modules of FFT - psychoeducation, communication skills training and problem solving - are adapted to address the clinical issues presented by suicidal bipolar adults or adolescents and their families.

RESULTS

Key objectives of the treatment are to help the family recognize that suicidal behavior is a part of the pathophysiology of bipolar disorder but that it is also to some extent under environmental control. Thus, the family is in a unique position to develop and help assure the success of a suicide prevention contract. A case study of an adolescent with suicidal behavior is presented.

CONCLUSIONS

Future research should include a focus on: (i) cross-cultural issues in suicide and bipolar disorder; and (ii) the adaptation of interventions shown to be effective in reducing suicidal behaviors in non-bipolar populations.

Effect of race and sex on primary care physicians' diagnosis and treatment of late-life depression

OBJECTIVES

To examine primary care physician (PCP) contributions toward racial and sex differences in the diagnosis and treatment of late-life depression.

DESIGN

Survey using a computerized instrument incorporating video interviews and text, with volunteer PCPs randomly assigned to one of four standardized video vignettes of an elderly patient depicting late-life depression. Vignettes differed only in the patient/actor's race (white/African-American) or sex.

SETTING

American Academy of Family Physicians meeting, San Diego, California, 2002.

PARTICIPANTS

One hundred seventy-eight U.S.-practicing postresidency PCPs who were asked to participate in a clinical decision-making study.

MEASUREMENTS

The computerized survey instrument assessed PCPs' diagnoses, first-line treatment and management recommendations, and judgment of personal characteristics/behaviors for the patients in the vignettes.

RESULTS

Eighty-five percent of all PCPs correctly diagnosed the elderly patient(s) with major depression. There were no significant differences in the diagnosis of depression, treatment recommendations, or PCP assessment of most patient characteristics by the race or sex of the patient/actor in the vignette, but PCP characteristics, most notably the location of medical school training (U.S. vs international), affected the likelihood of a depression diagnosis and treatment recommendations.

CONCLUSION

Given standardized symptom-pictures, PCPs are just as likely to diagnose and treat depression in African-American as in white older people, suggesting that bias based simply on apparent patient race is not a likely explanation for the lower rates of depression diagnosis and treatment in older African Americans. PCPs who have trained at international medical schools may benefit from targeted training initiatives on the diagnosis and treatment of late-life depression.

The Effects of Race and Criminal Justice Involvement on Access to Atypical Antipsychotic Medications Among Persons with Schizophrenia

This study examined the impact of race and arrest history on the likelihood of being prescribed, and maintaining an atypical antipsychotic prescription for 90 or more days among patients with schizophrenia in the community. Participants were 224 adults with schizophrenia-spectrum disorders receiving services in public-sector mental health systems in North Carolina. The data used for this report were from a subsample of a larger group of participants being followed in an observational study and consisted of individuals who were prescribed either an atypical or conventional antipsychotic medication for 90 or more days. The purpose of the analyses presented here was to investigate differences in the likelihood of being prescribed an atypical antipsychotic by demographic and other characteristics. Logistic regression analysis indicated that African American patients were significantly less likely to receive atypical antipsychotics than their white counterparts, even when controlling for key clinical and demographic variables. However, white patients with a history of arrest were no more likely than black patients to receive atypical antipsychotics; that is, minority racial status and criminal involvement each functioned to limit patients' access to the novel medications. Implications for equal access to mental health services, in this case, effective psychopharmacologic treatment, are discussed.

Evidence-based assessment of personality disorders

The purpose of this article is to provide a foundation for the development of evidence-based guidelines for the assessment of personality disorders, focusing in particular on integrated assessment strategies. The general strategy recommended herein is to first administer a self-report inventory to alert oneself to the potential presence of particular maladaptive personality traits followed by a semistructured interview to verify their presence. This strategy is guided by the existing research that suggests particular strengths of self-report inventories and semistructured interviews relative to unstructured clinical interviews. However, the authors also consider research that suggests that further improvements to the existing instruments can be made. The authors emphasize, in particular, a consideration of age of onset, distortions in self-perception and presentation, gender bias, culture and ethnicity, and personality change.

What Do Clinicians Expect? Comparing Envisioned and Reported Violence for Male and Female Patients

Mental health professionals' (MHPs') accuracy in assessing the risk of violence in female patients is particularly limited. Based on assessments made by 205 MHPs of 605 patients in an emergency room, this study explored potential causes of MHPs' poorer accuracy in assessing women's potential for violence. The dimensions that underlie MHPs' envisioned violence in patients were identified and were compared with those that characterized patients' reported violence during a 6-month follow-up period. There were three key findings from their study. First, violence envisioned by MHPs differed depending on their professional role and varied in its congruence with patients' reported violence. Second, patients' violence was organized by dimensions of domesticity and substance relatedness; women's violent incidents were more domestic than were men's. Third, when MHPs envisioned violence that was highly conditional on psychiatric deterioration and medication noncompliance, violence often did not occur.

The diagnosis of neurological disorders in older adults

Are neurological disorders overdiagnosed in older adults? Previous reports suggest that age bias may lead to diagnostic inaccuracies for older adult clients. In the present study, the average test scores for community-dwelling 38-year-old and 74-year-old individuals were presented as the results for a 38-year-old client and a 74-year-old client, respectively. Neuropsychologists did not make diagnoses of neurological disorder or dementiafor either of the clients. The results from this study indicate that age bias is not as serious a problem among neuropsychologists as many psychologists once believed.

Current issues in the assessment of personality disorders

Most patients will have clinically significant maladaptive personality traits. These personality traits can substantially complicate the effective treatment of other mental disorders, and they can also be the focus of effective treatment. The assessment of personality disorders is of considerable clinical importance. However, this assessment can also be highly problematic. This article discusses the major issues in the assessment of personality disorders (eg, differentiation from other mental disorders, from normal personality functioning, and gender bias) and summarizes existing research on the convergent and discriminant validity of the semistructured interviews and self-report inventories, which have been developed to improve the reliability and validity of personality disorder assessment.

Perceived dysfunction of male-typed and female-typed DSM-IV personality disorder criteria

To determine whether female-typed personality disorders are associated with a different pattern of dysfunction than male-typed disorders, lay judges (N = 216) estimated the amount of social impairment, occupational impairment, and personal distress related to symptoms of personality disorders. Results for both the subset of six disorders originally rated by clinician judges in the research of Funtowicz and Widiger (1999) and for a larger set of nine disorders revealed a pattern originally reported by Funtowicz and Widiger where female-typed disorders were associated with relatively higher ratings of personal distress, whereas male-typed disorders were associated with relatively higher ratings of social (and sometimes occupational) impairment. Findings are discussed with respect to the emphasis of different forms of dysfunction for male- and female-typed disorders, lay versus clinician judgments, and directions for future research.