Revising psychiatric diagnostic categorisation of immigrant patients after using the Cultural Formulation in DSM-IV

Patient identity narratives through the cultural formulation interview in a New York City outpatient clinic

Anthropologists have critiqued cultural competence programs in medical settings while introducing mental health clinicians to social theories on culture for practice. We explore how patients articulated narratives about themselves and how clinicians responded to such narratives through an intervention known as the Cultural Formulation Interview that anthropologists have helped develop. We conducted over 500 hours of fieldwork from 2014 to 2019 at an outpatient clinic in New York, analyzing multiple data (participant observation, medical records, patient-clinician sessions, and individual debriefing interviews) in a trial joining clinical and ethnographic methods. Our study enrolled 45 patients and six clinicians, yielding 117 patient-clinician appointments and 98 debriefing interviews. Most patients differed in how they presented their identities through demographic forms and discussed them in sessions with their clinicians. Two-thirds of the patients drew connections between their personal identities and experiences of mental illness. These results reveal why cultural identities should not be taken for granted in clinical settings.

Unlocking asylum seekers' voices: protocol of a mixed-method clinical study on the use of the cultural formulation interview with asylum seekers in Belgium

Background

Despite a high prevalence of mental disorders among asylum seekers, many barriers to mental healthcare exist. Cultural and contextual factors strongly influence the experience and expression of psychological distress, putting asylum seekers at greater risk of misdiagnosis and inappropriate treatment. The Cultural Formulation Interview (CFI) is a useful tool to map out cultural and contextual factors of mental disorders; however, to the best of our knowledge, it has not yet been investigated in asylum seekers specifically. The primary aim of this study is to evaluate the value of the CFI in the psychiatric assessment of asylum seekers. Second, we will describe the themes relevant to psychiatric distress in asylum seekers that are identified by the CFI. In addition, asylum seekers' experience of the CFI will be evaluated.

Methods and analysis

This cross-sectional, mixed-method clinical study aims to recruit a group of 60-80 asylum seekers (age 15-29) with mental health symptoms. Data will be collected using structured (MINI, PCL-5, HDRS-17, WHOQoL-BREF & BSI) and semi-structured (CFI & CFI-debriefing) questionnaires to assess cultural background, contextual factors, and illness severity. Multidisciplinary case discussions will be held after the completion of interviews, following a methodological stepped approach. Combining qualitative and quantitative research techniques, this study aims to generate reliable knowledge on working with the CFI in asylum seekers. Based on the findings, recommendations for clinicians will be developed.

Discussion

This study addresses the knowledge gap on using the CFI in asylum seekers. Compared to prior studies, it will provide new insights into the use of the CFI in the specific context of working with asylum seekers.

Ethics and dissemination

Prior research on the CFI in asylum seekers is limited, partly because of their high vulnerability and low access to care. The study protocol has been tailored in close collaboration with several stakeholders and validated after piloting. Ethical approval has already been obtained. Together with the stakeholders, the results will be translated into guidelines and training materials. Recommendations to policymakers will also be provided.

The Evolving Culture Concept in Psychiatric Cultural Formulation: Implications for Anthropological Theory and Psychiatric Practice

For thirty years, psychiatrists and anthropologists have collaborated to improve the validity of psychiatric diagnosis. This collaboration has produced the DSM-IV Outline for Cultural Formulation (OCF) and the DSM-5 Cultural Formulation Interview (CFI). Nonetheless, some anthropologists have critiqued the concept of culture in DSM-5 as too focused on patient meanings and not on clinician practices. This article traces the evolution of the culture concept from DSM-IV through DSM-5-TR by analyzing publications from the American Psychiatric Association on the OCF and CFI alongside scholarship in psychiatry and anthropology. DSM-IV relied on a culture concept of coherent ethnic communities sharing coherent cultures, primarily for minoritized ethnoracial individuals in the United States. Changing demographics and newer immigration patterns around the world deminoritized the culture concept for DSM-5. After George Floyd's death and demands for social justice, the culture concept in DSM-5-TR emphasized social structures. The article proposes an intersubjective model of culture through which patients and clinicians work through similarities and differences. It recommends a revised formulation that attends to clinician practices such as communicating, diagnosing, recommending treatments, and documenting, beyond collecting patient meanings. It also raises the question of whether an intersubjective model of culture prompts reconsiderations of culture-related text in other sections of the DSM. The social sciences can redirect attention to the clinician's culture of biomedicine to close patient health disparities.

A Central Clearing Clinic to Provide Mental Health Services for Refugees in Germany

Objective: To determine migration related distress pattern in refugees and feasibility of a de novo established, central low-threshold outpatient clinic serving more than 80,000 newly arrived refugees in the metropole of Berlin. Methods: In an observational cohort study the relative prevalence of major psychiatric disorders by age, place of living within berlin, language and region of origin were assessed in a refugee cohort from 63 nationalities speaking 36 languages. Findings: Within 18 months, a total of 3,096 cases with a mean age of 29.7 years (11.7) have been referred from all 12 districts and 165 of 182 subdistricts of Berlin to the CCC. 33.7% of the patients were female. The three most frequent diagnoses were unipolar depression (40.4%), posttraumatic stress disorder (24.3%), and adjustment disorder (19.6%). Conclusion: The present data gives insight into the distribution of mental disorders in a large sample of refugees and provides evidence that a CCC is an effective service to quickly and broadly provide psychiatric consultations and thus to overcome classical barriers refugees usually experience in the host communities. In Berlin, Germany, and Europe treatment resources for this population should focus on stress and trauma related disorders.

Using the Cultural Formulation Interview in Denmark: Acceptability and clinical utility for medical doctors and migrant patients

Previous studies have shown the importance of focusing on the cultural background of migrant patients in the psychiatric assessment. The Cultural Formulation Interview (CFI) offers a patient-focused approach to foreground the cultural context of the patient in the clinical encounter. Our objective was to explore the acceptability and clinical utility of the CFI for physicians and its acceptability for migrant patients seen at a transcultural mental health clinic in Denmark. In this study, the CFI was used in a second session following the standard clinical assessment to explore what additional information was gained from the CFI. Data on the use of the CFI data were collected immediately after the interview with questionnaires for medical doctors (MDs) (N = 12) and patients (N = 71). The findings showed that the CFI, in addition to standard assessment, was useful to the MDs for planning the treatment (60.0%) and for exploring the patients' view on their cultural and social context (74.7%), but less so for the diagnostic process (9.9%). Patients reported high overall satisfaction with the CFI (93.0%) and viewed it as a welcome opportunity to tell their story. The findings add to existing knowledge on the CFI in terms of acceptability for patients of a primarily Middle Eastern origin and patients using an interpreter during the CFI session. Based on the findings of this study, the CFI is recommended to clinicians for treatment planning purposes and for exploring the cultural and social context of the patient.

Patients' and clinicians' experiences of the DSM-5 Cultural Formulation Interview: A mixed method study in a Swedish outpatient setting

This study is an evaluation of clinicians' and patients' experiences of the core Cultural Formulation Interview (CFI) in DSM-5. The CFI provides a framework for gathering culturally relevant information, but its final form has not been sufficiently evaluated. Aims were to assess the Clinical Utility (CU), Feasibility (F) and Acceptability (A) of the CFI for clinicians and patients, and to explore clinicians' experiences of using the CFI in a multicultural clinical setting in Sweden. A mixed-method design was applied, using the CFI Debriefing Instrument for Clinicians (N = 15) and a revised version of the Debriefing Instrument for Patients (N = 114) (DIC and DIP, scored from -2 to 2). Focus group interviews were conducted with clinicians. For patients (response rate 50%), the CU mean was 0.98 (SD = 0.93) and F mean 1.07 (SD = 0.83). Overall rating of the interview was 8.30 (SD = 1.75) on a scale from 0 and 10. For clinicians (response rate 94%), the CU mean was 1.14 (SD = 0.52), F 0.58 (SD = 0.93) and A 1.42 (SD = 0.44). From clinician focus-group interviews, the following themes were identified: approaching the patient and the problem in a new manner; co-creating rapport and understanding; and affecting clinical reasoning and assessment. Patients and clinicians found the CFI in DSM-5 to be a feasible, acceptable, and clinically useful assessment tool. The focus group interviews suggested that using the CFI at initial contact can help make psychiatric assessment patient-centred by facilitating patients' illness narratives. We argue for further refinements of the CFI.

The Cultural Formulation Interview since DSM-5: Prospects for training, research, and clinical practice

While social science research has demonstrated the importance of culture in shaping psychiatric illness, clinical methods for assessing the cultural dimensions of illness have not been adopted as part of routine care. Reasons for limited integration include the impression that attention to culture requires specialized skills, is only relevant to a subset of patients from unfamiliar backgrounds, and takes too much time to be useful. The DSM-5 Cultural Formulation Interview (CFI), published in 2013, was developed to provide a simplified approach to collecting information needed for cultural assessment. It offers a 16-question interview protocol that has been field tested at sites around the world. However, little is known about how CFI implementation has affected training, health services, and clinical outcomes. This article offers a comprehensive narrative review that synthesizes peer-reviewed, published studies on CFI use. A total of 25 studies were identified, with sample sizes ranging from 1 to 460 participants. In all pilot CFI studies 960 unique subjects were enrolled, and in final CFI studies 739 were enrolled. Studies focused on how the CFI affects clinical practice; explored the CFI through research paradigms in medical communication, implementation science, and family psychiatry; and examined clinician training. In most studies, patients and clinicians reported that using the CFI improved clinical rapport. This evidence base offers an opportunity to consider implications for training, research, and clinical practice and to identify crucial areas for further research.

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.

Prolonged Grief Disorder and the Cultural Crisis

Prolonged grief disorder (PGD) is included as a new mental health disorder in the 11th edition of the International Classification of Diseases (ICD-11). Understandably, this has boosted research efforts to investigate this newcomer to psychopathology. However, the use of different diagnostic algorithms has resulted in substantially different prevalence rates both within and across cultural groups. Furthermore, global applicability of the new criteria outside of the Global North has not been yet been established. This perspective presents key findings from Asian research groups and discusses the roadblocks to unified PGD research, including the heterogeneric use of diagnostic algorithms and the lack of cultural compatibility of ICD-11 items. The authors discuss the key issues and address implications for practice.

Patient and clinician communication practices during the DSM-5 cultural formulation interview field trial

Cultural psychiatrists and medical anthropologists have collaborated to help clinicians screen for culture-related issues in patient explanatory models of illness and to enhance the clinical processes of engagement, diagnosis, and treatment planning. This effort prioritises patient perspectives on suffering and healing to counter the trend of symptom-based interviews which assume biologically determined models of mental disorders. The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes the Cultural Formulation Interview (CFI), a semi-structured questionnaire for eliciting patient explanatory models. This paper analyses specific linguistic meanings and practices that could account for patient perceptions of improved rapport with clinicians, clinician perceptions of improving information gathering, and cultural models of health and illness during the DSM-5 field trial piloting the CFI. Twenty-seven audiotapes were analysed through the Roter Interaction Analysis System (RIAS), a standardised method for examining medical interviews based on ethnographic studies of small-group communication. After an introduction with procedural and reassurance statements to orient communication, the CFI's open-ended questions elicited patients' opinions on interpersonal, environmental, and biomedical information. Clinicians made facilitation and activation statements for patients to speak more and informed patients about what to expect. Patients constructed cultural models of illness that weaved interpersonal, environmental, and biomedical information. Clinicians and patients made rapport-building statements to each other. A RIAS-derived patient-centred score indicates that CFI sessions addressed patient concerns. Our work offers a way to analyse the discursive construction of culture in health settings and patient-centredness through detailed examinations of linguistic meanings and practices.

Assessment and treatment of asylum seekers after a suicide attempt: a comparative study of people registered at mental health services in a Swedish location

BACKGROUND

Even though asylum seekers are considered vulnerable to mental ill-health, knowledge of their suicidal behaviour is limited. The aim of this study was to improve our understanding of factors that influence the clinical assessment of asylum seekers who have attempted suicide compared to the assessment of non-asylum seekers.

METHODS

The study focused on 88 asylum seekers registered for suicide attempts in mental health services 2005-2009, who were matched for age and gender and compared with 88 suicide attempters with Swedish personal identity numbers. The medical records were analysed with a quantitative protocol, focusing on social risk and protective factors, health history, current clinical picture as well as the assessment procedure, diagnostics, patterns of treatment and follow-up in this clinical group. Data was analysed using the chi-square test, Fisher's exact probability test, and the Mann-Whitney U test.

RESULTS

As in earlier studies, asylum seekers were more traumatized, had different social risk factors and received different diagnoses than the controls. Asylum seekers were referred to less specialized follow-up after treatment, in spite of their health history and of previous and current clinical pictures indicating a similar or--in the case of the female asylum seekers--more serious mental health condition. Female asylum seekers also received more intense and prolonged in-patient treatment than female controls. Asylum seekers appeared to have social networks more often than the control group. However, there was less documentation of the social context, previous suicidal behaviour, and on suicide in the family and close environment of the asylum-seeking men. Information on suicidal intent was lacking in a majority of both groups. The time relation of the suicide attempt and the asylum process suggested the importance of the asylum decision, as well as the possible role of earlier mental health problems and premigration stress, for the suicidal behaviour.

CONCLUSIONS

The groups had different sets of risk factors and clinical pictures. There was a lack of early and thorough exploration of suicide intent for both groups, and of contextual and subjective factors for the asylum seekers. Differences in follow-up indicate unequal access to care.