Ademola B. Adeponle

Using the Cultural Formulation to Resolve Uncertainty in Diagnoses of Psychosis Among Ethnoculturally Diverse Patients

OBJECTIVE The aim of the study was to assess the impact of systematic use of the DSM-IV-TR cultural formulation on diagnoses of psychotic disorders among patients of ethnic minority and immigrant backgrounds referred to a cultural consultation service (CCS) in Canada. METHODS The study entailed a review of medical records and case conference transcripts of 323 patients seen in a ten-year period at the CCS to determine factors associated with change in the diagnosis of psychotic disorders by the CCS. Logistic regression analysis was used to identify variables associated with changes in diagnosis. RESULTS A total of 34 (49%) of the 70 cases with an intake (referral) diagnosis of a psychotic disorder were rediagnosed as nonpsychotic disorders, whereas only 12 (5%) of the 253 cases with an intake diagnosis of a nonpsychotic disorder were rediagnosed as a psychotic disorder (p<.001). Major depression, posttraumatic stress disorder (PTSD), adjustment disorder, and bipolar affective disorder were the common disorders diagnosed with use of the cultural formulation. Rediagnosis of a psychotic disorder as a nonpsychotic disorder was significantly associated with being a recent arrival in Canada (odds ratio [OR]=6.05, 95% confidence interval [CI]=1.56-23.46, p=.009), being nonblack (OR=3.72, CI=1.03-13.41, p=.045), and being referred to the CCS by nonmedical routes (such as social work or occupational therapy) (OR=3.23, CI=1.03-10.13, p=.044). CONCLUSIONS Misdiagnosis of psychotic disorders occurred with patients of all ethnocultural backgrounds. PTSD and adjustment disorder were misidentified as psychosis among immigrants and refugees from South Asia. Studies are needed that compare clinical outcomes of use of cultural consultation with outcomes from use of other cultural competence models.

Family participation in treatment, post-discharge appointment and medication adherence at a Nigerian psychiatric hospital.

In low-income countries, clinicians must seek strategies to improve treatment adherence that are non-resource intensive and easily integrated into existing treatment structures. We conducted a prospective observational cohort study to investigate the relationship of family engagement in treatment during hospitalisation with post-discharge appointment and medication adherence in 81 patients from a Nigerian psychiatric hospital. After controlling for gender, diagnosis, mental state at discharge, and marital status, family involvement was significantly associated with appointment (P=0.047) but not medication adherence (P=0.590). Studies are needed to determine whether interventions based on engaging families in treatment can improve post-discharge adherence in this setting.

Clinician reasoning in the use of cultural formulation to resolve uncertainty in the diagnosis of psychosis.

We examined how the process of cultural formulation contributes to diagnostic assessment of patients with psychotic disorders at a specialized Cultural Consultation Service (CCS). Specifically, we investigated the reasoning process used to resolve uncertainty of psychotic disorder diagnosis in African immigrant patients referred to the CCS for assessment of possible psychotic disorder. Qualitative thematic analysis of 23 clinical case conference transcripts was used to identify clinicians’ reasoning styles. Use of the CF appears to facilitate the emergence of a rule-governed reasoning process that involved three steps: (i) problematize the diagnosis of the intake ‘psychosis’ symptoms or behavior; (ii) elaborate explanations as to why the symptoms or behavior may or may not be psychosis; and (iii) confirm the diagnosis of psychosis or re-interpret as non-psychosis. Prototypes and exemplars drawn from previous experience in intercultural work featured prominently in clinicians’ reasoning. Prototypes were crucial in diagnostic decision-making and appear to be important sources of both clinician expertise and bias, and may need to be targeted specifically in cultural competence training.

Efficacy of Tai Chi for chronic musculoskeletal pain conditions: Is the evidence ready for meta‐analysis? Comment on the article by Hall et al

thickening)” (1). This is similar to the OMERACT definition, which describes synovial hypertrophy as “abnormal hypo-echoic, intra-articular tissue that is non-displaceable and poorly compressible and which may exhibit Doppler signal” (2). It is therefore reasonable to assume that these terms are interchangeable for the purposes of US studies. With regard to the use of a warm-water bath, we believe that although this could potentially vasodilate cutaneous and subcutaneous vasculature, it is unlikely to influence deeper structures, including the synovium. The use of cold gels, extremes of ambient temperature, or exercise prior to US examination are additional variables that are not normally measured in these studies. We therefore conclude that the use of a warm-water bath did not unduly affect our findings. Ceccarelli et al observed no significant difference between patients with rheumatoid and undifferentiated arthritis regarding the presence of erosions of the fifth MTP joint. In both studies, the number of patients was small and it is possible that variations in disease duration, genetic profiles, and other factors may contribute to divergent findings in such a heterogeneous disease. Both papers confirm that US is a useful and expeditious modality in the assessment of patients with early inflammatory arthritis, and the extension of these findings to larger numbers would be helpful. We would like to acknowledge the work of Dr. Alarcón and her colleagues in relation to the ultrasonographic detection of erosions in the hands and feet in the absence of radiographic damage (3). As our paper was submitted under the category of Contributions From the Field, the word count and number of references we could include was restricted. In addition, our study focused solely on the US imaging of the fifth MTP joint in patients with both differentiated and undifferentiated early inflammatory arthritis. Taken together, these and other studies highlight the role of US in the early detection of joint damage.

Perinatal depression in Nigeria: perspectives of women, family caregivers and health care providers

BackgroundPerinatal maternal depression is common and undertreated in many sub-Saharan African countries, including Nigeria. While culture shapes the social determinants and expression of depressive symptoms, there is a dearth of research investigating these processes in African contexts.MethodsTo address this gap, we conducted in-depth interviews with 14 women with perinatal depression, 14 of their family caregivers and 11 health providers, using the McGill Illness Narrative Interview as part of a larger trial of a stepped-care intervention. Interpretation of themes was guided by cultural constructivist and critical anthropological perspectives that situate perinatal depression in its complexity as a disorder that is embedded in webs of social relations and embodied practices.ResultsStudy respondents used idioms of distress that identified perinatal conditions that consist of somatic, affective, cognitive and behavior symptoms found in depressive disorders. Respondents viewed mental health problems in the perinatal period as tied to sociomoral concerns over gender roles and women’s position within the household. Conflict between women’s effort to be assertive to address interpersonal problems, while needing to be seen as non-aggressive contributed to their distress. Causal explanations for depression included husband’s lack of care, family problems, “spiritual attack”, having a female child when a male child was desired, and not resting sufficiently after childbirth. Guilt about breaching social norms for women’s conduct contributed to self blame, and feelings of shame.ConclusionsClinical assessment and interventions as well as public health prevention strategies for perinatal depression in global mental health need to consider local social contexts and meanings of depression, which can be explored with narrative-based methods.

More antidepressants for African Americans with coronary heart disease? Maybe—maybe not

Waldman et al reported that African Americans with coronary heart disease (CHD) are less often prescribed antidepressants compared to white patients with similar levels of depressive symptoms. They urged more careful assessment of African American patients to reduce this disparity. Ethnic disparities in health care are well documented, and depression needs to be adequately treated, irrespective of race or ethnicity. Waldman et al correctly suggested that physician practices may influence less antidepressant use among African Americans. They also suggested that patient stigma, low education, and access may be factors. Rather than simply an issue of mental health literacy or compliance, however, apprehensions of African Americans toward antidepressants may reflect a conscientious decision-making process. Results from the 1998 General Social Survey confirmed that African Americans are less willing to use antidepressants, largely due to skepticism regarding antidepressant efficacy and beliefs about side effects, controlling for socioeconomic and educational status, religious involvement, medication knowledge, and physician trust. Similarly, West Indian immigrants to Canada have explained their reluctance to use mental health services in part on a perceived overwillingness of physicians to rely on pharmaceutical interventions. The concerns of African American patients seem reasonable. Half of African American patients on antidepressants in Waldman et al had BDI scores b10. A recent study demonstrated that selective publication of positive trials has substantially overestimated the efficacy of antidepressant medications. There are persistent and troublesome side effects of antidepressants, including sexual side effects, drowsiness, and weight gain, but more than half of patients are not told about potential side effects when therapy is initiated. A substantial number of patients in primary care settings discontinue depression treatment within 1 month of initiation, and as many as one half discontinue treatment within 3 months. On the basis of their findings, Waldman et al argue for more careful depression assessment to improve care. We agree that better care is needed. There is no evidence,

International Medical Graduates in Psychiatry: Cultural Issues in Training and Continuing Professional Development:

A position paper developed by the Canadian Psychiatric Association’s Education Committee and approved by the CPA’s Board of Directors on August 15, 2016.

Varieties of Global Psychology: Cultural Diversity and Constructions of the Self

Throughout its history as an academic discipline, psychology has used Western subjects as the basis for research and theory building. The resultant models are shot through with assumptions about the nature of the person presented as universal truths rather than ones contextualized in time and place. This chapter interrogates some of the assumptions of Western psychology to open up a conversation about the diversity of human experience in health and illness. It draws from cultural constructivist and critical anthropological perspectives that view notions of self as situated and shaped by local interpretive practices inscribed within and constrained by historical, political economic contexts. Notions of self are viewed as cultural constructions that reflect collective understandings of phenomena, experience, and behavior. By laying bare these contexts, the chapter shows some of the building blocks of psychological structure and function, the range of methodologies needed to advance this exploration, and the political constraints that continue to marginalize or silence diverse voices and perspectives.

Diverse Approaches to Recovery from Severe Mental Illness

Recovery is an individual process that involves living a satisfying life even with limitations caused by mental illness (Anthony 1993). In this chapter, the authors discuss the conceptualization and implementation of recovery in three case studies from the USA, New Zealand, and Nigeria. In all three cases, recovery is facilitated by (1) ensuring that people with mental illness can fully participate and thrive within their respective societies; (2) diminishing barriers to social inclusion and full citizenship at individual, familial and community levels; and (3) reforming mental health services to be humane, empowering and holistic. This chapter demonstrates that the recovery model provides scaffolding to give shape to reform of mental health services, while allowing flexibility for adaptation to local circumstances and values.

The University of Manitoba Psychiatry Toolkit: Development and Evaluation

ObjectiveThe authors developed and measured the subsequent utilization of a web-based point-of-care information tool and meta-search filter, the University of Manitoba Psychiatry Toolkit, as well as conduct an evaluation of its impact on physicians’ information seeking.MethodsEvaluation entailed analysis of toolkit web page utilization data from user visits to the web-based toolkit, as well as an online survey distributed to psychiatrists and resident trainees to assess information gathering behaviors and attitudes regarding various sources of medical information.ResultsElectronic resources and colleagues were the preferred sources for gathering health information, while inadequate time and search skills were ranked as important barriers. Age and physician cadre influenced toolkit use. Majority of respondents used the Psychiatry Toolkit to answer a clinical question, and urgency of the clinical problem influenced their decision to use it.ConclusionsThe Psychiatry Toolkit assists psychiatrists and residents in finding answers to clinical questions arising at point-of-care, helping enhance the ongoing educational needs of physicians.