Sociocultural Framework for Psychiatric Case Formulation

ABSTRACT

A Cultural Formulation Interview (CFI) field trial in India, widely reported racist violence in the United States, and casteist and religious communal conflicts in India highlighted inattention to structural issues affecting mental health problems in the Outline for Cultural Formulation (OCF) and the CFI in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Consequently, we revised the OCF as a sociocultural formulation (SCF) to better consider structures of society and culture. We studied and compared clinicians' ratings of SCF case formulations from a constructed assessment instrument (SCF Interview [SCFI]) and the CFI. Socio-cultural formulations from SCFI interviews were rated higher for details of societal structural impact, and overall interrater agreement was better. CFI interviews were rated higher for clinical rapport. Revision of the CFI should enhance consideration of structural issues and incorporate them in SCFs that better integrate assessment process and case formulation content. The need to acknowledge structural sources of mental health problems is clear, and our study indicates how a sociocultural framework may be used for that.

Clinical value of the cultural formulation interview in Pune, India

CONTEXT

Development of the cultural formulation interview (CFI) in DSM-5 required validation for cross-cultural and global use.

AIMS

To assess the overall value (OV) of CFI in the domains of feasibility, acceptability, and utility from the vantage points of clinician-interviewers, patients and accompanying relatives.

SETTINGS AND DESIGN

We conducted cross-sectional semi-structured debriefing interviews in a psychiatric outpatient clinic of a general hospital.

MATERIALS AND METHODS

We debriefed 36 patients, 12 relatives and eight interviewing clinicians following the audio-recorded CFI. We transformed their Likert scale responses into ordinal values - positive for agreement and negative for disagreement (range +2 to -2).

STATISTICAL ANALYSIS

We compared mean ratings of patients, relatives and clinician-interviewers using nonparametric tests. Clinician-wise grouping of patients enabled assessment of clinician effects, inasmuch as patients were randomly interviewed by eight clinicians. We assessed the influence of the presence of relatives, clinical diagnosis and interview characteristics by comparing means. Patient and clinician background characteristics were also compared.

RESULTS

Patients, relatives and clinicians rated the CFI positively with few differences among them. Patients with serious mental disorders gave lower ratings. Rating of OV was lower for patients and clinicians when relatives were present. Clinician effects were minimal. Clinicians experienced with culturally diverse patients rated the CFI more positively. Narratives clarified the rationale for ratings.

CONCLUSIONS

Though developed for the American DSM-5, the CFI was valued by clinicians, patients and relatives in out-patient psychiatric assessment in urban Pune, India. Though relatives may add information and other value, their presence in the interview may impose additional demands on clinicians. Our findings contribute to cross-cultural evaluation of the CFI.

Interpreting "statistical hypothesis testing" results in clinical research

Difference between “Clinical Significance and Statistical Significance” should be kept in mind while interpreting “statistical hypothesis testing” results in clinical research. This fact is already known to many but again pointed out here as philosophy of “statistical hypothesis testing” is sometimes unnecessarily criticized mainly due to failure in considering such distinction. Randomized controlled trials are also wrongly criticized similarly. Some scientific method may not be applicable in some peculiar/particular situation does not mean that the method is useless. Also remember that “statistical hypothesis testing” is not for decision making and the field of “decision analysis” is very much an integral part of science of statistics. It is not correct to say that “confidence intervals have nothing to do with confidence” unless one understands meaning of the word “confidence” as used in context of confidence interval. Interpretation of the results of every study should always consider all possible alternative explanations like chance, bias, and confounding. Statistical tests in inferential statistics are, in general, designed to answer the question “How likely is the difference found in random sample(s) is due to chance” and therefore limitation of relying only on statistical significance in making clinical decisions should be avoided.

Biomedical markers and psychiatric morbidity of neurasthenia spectrum disorders in four outpatient clinics in India

CONTEXT

Disorders of unexplained fatigue are researched globally and debated prominently concerning their biomedical and psychiatric comorbidity. Such studies are needed in India.

AIMS

To identify biomedical markers and psychiatric morbidity of disorders of severe unexplained fatigue or weakness with disability, designated neurasthenia spectrum disorders (NSDs). To compare biomedical markers of patients with controls. To study correlation between biomedical markers and psychiatric morbidity.

SETTINGS

Four specialty outpatient clinics of Psychiatry, Medicine, Dermatology, and Ayurved of an urban general hospital.

DESIGN

Case-control study for biomedical markers. Diagnostic interviews for assessment of psychiatric morbidity.

MATERIALS AND METHODS

Patients (N = 352) were recruited using screening criteria and Structured Clinical Interview for DSM-IV screening module. They were compared with controls (N = 38) for relevant biomedical markers. Psychiatric morbidity was assessed with SCID-I interviews, Hamilton scales, and Symptom Check List-90 (SCL-90). Correlations between a nutritional index and axis I morbidity were studied.

STATISTICAL ANALYSES

Frequencies and means of biomedical markers and psychiatric diagnoses were compared and associations assessed with regression analysis.

RESULTS

Corrected arm muscle area (CAMA) was significantly lower among patients (P < 0.001), but not anemia. Anxiety (73.0%) and somatoform (61.4%) disorders, especially nonspecific diagnoses, were more frequent than depressive disorders (55.4%). Generally, Hamilton and SCL scores were lowest in Ayurved clinic, and highest in Psychiatry clinic. Presence of Generalized Anxiety Disorder (GAD) and adjustment disorders correlated with low nutritional index.

CONCLUSIONS

Malnutrition or de-conditioning that may explain weakness need to be considered in the management of NSDs in India, particularly with comorbid GAD or adjustment disorders. Weakness and anxiety, rather than fatigue and depression, are distinct features of Indian patients. SCL may be more useful than categorical diagnoses in NSDs. NSDs are an independent entity with nonspecific psychiatric comorbidity. Cross clinic differences among patients with similar complaints highlight need for idiographic studies.

Prediction of outcome in depression by negative symptoms

Negative symptoms have been assessed in 34 cases of major endogenous depression (RDC) using the Scale for Assessment of Negative Symptoms. Correlation coefficients between negative symptoms and improvement rated on a 5-point scale were determined. Poverty of speech, affective flattening and avolition-apathy were found to be related with poor outcome. There was also a negative relationship between improvement and certain frequently occurring negative symptoms: inability to feel emotions, feelings of emptiness in thinking and feeling of avolition. High total negative symptom scores predicted poor outcome.