Annelle B. Primm

Issues for DSM-V: the role of culture in psychiatric diagnosis.

Renato D. Alarcón, MD, MPH,* Anne E. Becker, MD, PhD, ScM,†‡ Roberto Lewis-Fernández, MD,§¶ Robert C. Like, MD, MS, Prakash Desai, MD,** Edward Foulks, MD, PhD,†† Junius Gonzales, MD, MPH,‡‡ Helena Hansen, MD, PhD,§§ Alex Kopelowicz, MD,¶¶ Francis G. Lu, MD, María A. Oquendo, MD,*** and Annelle Primm, MD, MPH†††‡‡‡ for the Cultural Psychiatry Committee of the Group for the Advancement of Psychiatry

Race and ethnicity, mental health services and cultural competence in the criminal justice system: are we ready to change?

By the end of 2003, 3.2% of the U.S. adult population or 6.9 million adults were incarcerated, on probation or on parole. While non-whites constitute approximately 25% of the general U.S. population, they represent the majority of the prison (62%) and jail population (57%), a 33% increase since 1980. Approximately 15% of this prison and jail population has active symptoms of serious mental illness with two-thirds likely to have a co-occurring substance use disorder diagnosis. Meanwhile, the lack of adequate mental health and substance abuse treatment within all levels of the criminal justice system continues to exist. This is further exaggerated by the dearth of evidence showing appropriate cultural awareness and competence in delivery of these much needed services to a majority non-white population. This article will review the existing racial disparities present in the criminal justice system, the lack of appropriate psychiatric services, and the effect of cultural dissonance in service provision when services do exist. Policy implications and recommendations are included in the conclusion with a call for action to all agencies directly and indirectly affected by this multifaceted problem.

Mental health versus substance abuse treatment programs for dually diagnosed patients

The aim of this study was to assess the similarities and differences of patients with co-existing psychiatric and substance use disorders attending treatment in either a mental health setting or a substance abuse treatment setting. A total of 129 patients were assessed, including 65 individuals from the substance abuse treatment center and 64 individuals from the mental health program. Treatment records were reviewed for diagnoses and sociodemographic data. While the two groups were highly similar with regard to age and ethnicity, there were significant differences in psychiatric profile, with the substance abuse treatment group having less severe diagnoses and no patients with schizophrenia, while the mental health treatment group had a majority of patients with schizophrenia. Other differences in the two groups, such as marital and parental status, disability status, and medical problems appeared to be directly linked with the aforementioned diagnostic profile. These data suggest important differences in characteristics of patients with comorbid disorders that appear to be dependent on the type of treatment program they attend. For the most effective management, integrated treatment programs should be aware of these differences and tailor service provision accordingly.

Comparative Effectiveness of Standard versus Patient-Centered Collaborative Care Interventions for Depression among African Americans in Primary Care Settings: The BRIDGE Study

OBJECTIVE To compare the effectiveness of standard and patient-centered, culturally tailored collaborative care (CC) interventions for African American patients with major depressive disorder (MDD) over 12 months of follow-up. DATA SOURCES/STUDY SETTING Twenty-seven primary care clinicians and 132 African American patients with MDD in urban community-based practices in Maryland and Delaware. STUDY DESIGN Cluster randomized trial with patient-level, intent-to-treat analyses. DATA COLLECTION/EXTRACTION METHODS Patients completed screener and baseline, 6-, 12-, and 18-month interviews to assess depression severity, mental health functioning, health service utilization, and patient ratings of care. PRINCIPAL FINDINGS Patients in both interventions showed statistically significant improvements over 12 months. Compared with standard, patient-centered CC patients had similar reductions in depression symptom levels (-2.41 points; 95 percent confidence interval (CI), -7.7, 2.9), improvement in mental health functioning scores (+3.0 points; 95 percent CI, -2.2, 8.3), and odds of rating their clinician as participatory (OR, 1.48, 95 percent CI, 0.53, 4.17). Treatment rates increased among standard (OR = 1.8, 95 percent CI 1.0, 3.2), but not patient-centered (OR = 1.0, 95 percent CI 0.6, 1.8) CC patients. However, patient-centered CC patients rated their care manager as more helpful at identifying their concerns (OR, 3.00; 95 percent CI, 1.23, 7.30) and helping them adhere to treatment (OR, 2.60; 95 percent CI, 1.11, 6.08). CONCLUSIONS Patient-centered and standard CC approaches to depression care showed similar improvements in clinical outcomes for African Americans with depression; standard CC resulted in higher rates of treatment, and patient-centered CC resulted in better ratings of care.

A cluster randomized trial of standard quality improvement versus patient-centered interventions to enhance depression care for African Americans in the primary care setting: study protocol NCT00243425

BackgroundSeveral studies document disparities in access to care and quality of care for depression for African Americans. Research suggests that patient attitudes and clinician communication behaviors may contribute to these disparities. Evidence links patient-centered care to improvements in mental health outcomes; therefore, quality improvement interventions that enhance this dimension of care are promising strategies to improve treatment and outcomes of depression among African Americans. This paper describes the design of the BRIDGE (Blacks Receiving Interventions for Depression and Gaining Empowerment) Study. The goal of the study is to compare the effectiveness of two interventions for African-American patients with depression--a standard quality improvement program and a patient-centered quality improvement program. The main hypothesis is that patients in the patient-centered group will have a greater reduction in their depression symptoms, higher rates of depression remission, and greater improvements in mental health functioning at six, twelve, and eighteen months than patients in the standard group. The study also examines patient ratings of care and receipt of guideline-concordant treatment for depression.Methods/DesignA total of 36 primary care clinicians and 132 of their African-American patients with major depressive disorder were recruited into a cluster randomized trial. The study uses intent-to-treat analyses to compare the effectiveness of standard quality improvement interventions (academic detailing about depression guidelines for clinicians and disease-oriented care management for their patients) and patient-centered quality improvement interventions (communication skills training to enhance participatory decision-making for clinicians and care management focused on explanatory models, socio-cultural barriers, and treatment preferences for their patients) for improving outcomes over 12 months of follow-up.DiscussionThe BRIDGE Study includes clinicians and African-American patients in under-resourced community-based practices who have not been well-represented in clinical trials to improve depression care. The patient-centered and culturally targeted approach to depression care is a relatively new one that has not been tested in most previous studies. The study will provide evidence about whether patient-centered accommodations improve quality of care and outcomes to a greater extent than standard quality improvement strategies for African Americans with depression.Trial RegistrationClinicalTrials.gov NCT00243425

Using non-feature films to teach diversity, cultural competence, and the DSM-IV-TR outline for cultural formulation

ObjectiveFeature films have been used for teaching in psychiatry for many years to demonstrate diagnoses, but the use of documentary and instructional films in resident and staff cultural competence training have not been extensively written about in the medical and psychological literature. This article will describe the films that have been used by the authors and suggest methods for their use in cultural competence and diversity training.MethodsA literature search was done using MEDLINE and PsychINFO and the authors were asked to describe their teaching methods.ResultsOne article was found detailing the use of videotapes as a stimulus but not for cultural competence education, and two articles were found documenting the use of The Color of Fear as a stimulus for the discussion of racism. However, many educators use these films all across the country for the purpose of opening discussion about racism.ConclusionDocumentary, instructional, and public service announcements can be useful in teaching culturally competent assessment and treatment.

GAP-REACH: a checklist to assess comprehensive reporting of race, ethnicity, and culture in psychiatric publications.

Abstract Growing awareness of health and health care disparities highlights the importance of including information about race, ethnicity, and culture (REC) in health research. Reporting of REC factors in research publications, however, is notoriously imprecise and unsystematic. This article describes the development of a checklist to assess the comprehensiveness and the applicability of REC factor reporting in psychiatric research publications. The 16-item GAP-REACH© checklist was developed through a rigorous process of expert consensus, empirical content analysis in a sample of publications (N = 1205), and interrater reliability (IRR) assessment (N = 30). The items assess each section in the conventional structure of a health research article. Data from the assessment may be considered on an item-by-item basis or as a total score ranging from 0% to 100%. The final checklist has excellent IRR (&kgr; = 0.91). The GAP-REACH may be used by multiple research stakeholders to assess the scope of REC reporting in a research article.

Trauma and Diverse Child Populations

It has been estimated that as many as two-thirds of American youth experience a potentially life-threatening event before 18 years of age and that half have experienced multiple potentially traumatic events. Race, ethnicity, and culture influence the frequency and nature of these traumas and also the ways in which children react to traumatic events. The authors discuss the varied influences of cultural background on these reactions to trauma, the varying presentations of diverse children experiencing troubling reactions, and the need to provide treatment to children and their families in a fashion that is culturally sensitive and acceptable to diverse families.

Chronically mentally ill patients with and without substance use disorders: a pilot study.

The study was designed to assess characteristics of chronic mentally ill patients with and without a substance use disorder. Study patients (n=48) had either psychiatric illness alone (they received conventional psychiatric rehabilitation) or dual diagnoses (they received mental illness and substance abuse services). All patients were administered the Brief Symptom Inventory (BSI), the Client Satisfaction Questionnaire, the Perceived Social Support Scales, and the Composite International Diagnostic Interview. Higher proportions of dually diagnosed patients had schizophrenia, had higher scores on the BSI, and were less satisfied with treatment.

Lessons Learned: A "Homeless Shelter Intervention" by a Medical Student

ObjectiveThe authors explored the process of implementing a medical student-initiated program designed to provide computerized mental health screening, referral, and education in a homeless shelter.MethodsAn educational program was designed to teach homeless shelter staff about psychiatric disorders and culturally-informed treatment strategies. Pre- and post-questionnaires were obtained in conjunction with the educational program involving seven volunteer shelter staff. A computerized mental health screening tool, Quick Psycho-Diagnostics Panel (QPD), was utilized to screen for the presence of nine psychiatric disorders in 19 volunteer homeless shelter residents.ResultsShelter staffs’ overall fund of knowledge improved by an average of 23% on the basis of pre- /post- questionnaires (p=0.005). Of the individuals who participated in the mental health screening, 68% screened positive for at least one psychiatric disorder and were referred for further mental health care. At the 3- month follow-up of these individuals, 46% of those referred had accessed their referral services as recommended.ConclusionMedical student-initiated psychiatric outreach programs to the homeless community have the potential to reduce mental health disparities by both increasing access to mental health services and by providing education. The authors discuss educational challenges and benefits for the medical students involved in this project.