Esperanza Diaz

The expert consensus guideline series

Abstract Over the past decade, many new epilepsy treatments have been approved in the United States, promising better quality of life for many with epilepsy. However, clinicians must now choose among a growing number of treatment options and possible combinations. Randomized clinical trials (RCTs) form the basis for evidence-based decision making about best treatment options, but they rarely compare active therapies, making decisions difficult. When medical literature is lacking, expert opinion is helpful, but may contain potential biases. The expert consensus method is a new approach for statistically analyzing pooled opinion to minimize biases inherent in other systems of summarizing expert opinion. We used this method to analyze expert opinion on treatment of three epilepsy syndromes (idiopathic generalized epilepsy, symptomatic localization-related epilepsy, and symptomatic generalized epilepsy) and status epilepticus. For all three syndromes, the experts recommended the same general treatment strategy. As a first step, they recommend monotherapy. If this fails, a second monotherapy should be tried. Following this, the experts are split between additional trials of monotherapy and a combination of two therapies. If this fails, most agree the next step should be additional trials of two therapies, with less agreement as to the next best step after this. One exception to these recommendations is that the experts recommend an evaluation for epilepsy surgery after the third failed step for symptomatic localization-related epilepsies. The results of the expert survey were used to develop user-friendly treatment guidelines concerning overall treatment strategies and choice of specific medications for different syndromes and for status epilepticus.

Effects of ethnicity on psychotropic medications adherence.

We compared psychotropic medication adherence rates in monolingual-Hispanics (mostly Puerto Ricans), bilingual-Hispanics, and African–Americans as compared with Caucasians in 122 subjects recruited from a community mental health center (CMHC). After controlling for possible confounding factors monolingual-Hispanics and African–Americans had lower medication adherence rates (77% and 68%, respectively) than Caucasians (90%). Older age was a significant predictor of higher adherence among monolingual-Hispanics. Depressive symptoms were associated with lower adherence and more years of past treatment with higher adherence among Caucasians. Further studies are needed to better understand and improve adherence among Hispanics and African–Americans.

Perceived Needs and Service Use of Spanish Speaking Monolingual Patients Followed at a Hispanic Clinic

This study compared Spanish speaking monolingual patients at a Hispanic Clinic, with Hispanics and non-Hispanics at a conventional mental health center. A questionnaire in English and Spanish surveyed sociodemographic characteristics and subjectively reported health needs. The monolingual Hispanic Clinic patients perceived a significantly greater need for help with health and benefits, and better access to physical health care providers. Hispanics seen at the Hispanic Clinic report more difficulties managing medications than the other groups suggesting that this problem is not adequately addressed by receiving services in a culturally sensitive clinic, possibly due to the persistent effect of language barriers and low level of education. Additional interventions may be needed to address this problem.

Feasibility, acceptability and clinical utility of the Cultural Formulation Interview: mixed-methods results from the DSM-5 international field trial

BackgroundThere is a need for clinical tools to identify cultural issues in diagnostic assessment.AimsTo assess the feasibility, acceptability and clinical utility of the DSM-5 Cultural Formulation Interview (CFI) in routine clinical practice.MethodMixed-methods evaluation of field trial data from six countries. The CFI was administered to diagnostically diverse psychiatric out-patients during a diagnostic interview. In post-evaluation sessions, patients and clinicians completed debriefing qualitative interviews and Likert-scale questionnaires. The duration of CFI administration and the full diagnostic session were monitored.ResultsMixed-methods data from 318 patients and 75 clinicians found the CFI feasible, acceptable and useful. Clinician feasibility ratings were significantly lower than patient ratings and other clinician-assessed outcomes. After administering one CFI, however, clinician feasibility ratings improved significantly and subsequent interviews required less time.ConclusionsThe CFI was included in DSM-5 as a feasible, acceptable and useful cultural assessment tool.

Inconsistencies in Diagnosis and Symptoms Among Bilingual and English- Speaking Latinos and Euro-Americans

OBJECTIVE Little information is available about accuracy of diagnoses in clinical care for affective and other major mental disorders experienced by Latino patients. This study addressed two central research questions: Do Latinos have disproportionate rates of clinical diagnoses of major depression based on structured diagnostic interviews? Are diagnostic patterns consistent with patient profiles and medical record information? METHODS A total of 259 bilingual Latino, monolingual English-speaking Latino, and Euro-American patients aged 18 to 45 years with a history of severe depression or psychotic symptoms were compared across three clinical sites by using structured interviews. RESULTS Compared with Euro-Americans, bilingual Latinos had significantly higher rates of major depression and significantly lower levels of mania. No significant differences were found between monolingual English-speaking Latinos and Euro-Americans. CONCLUSIONS Results suggest that the diagnostic process is affected by an apparent association with cultural-linguistic influences, notably speaking English as a second language.

The Connecticut Latino Behavioral Health System: A culturally informed community-academic collaboration.

The Connecticut Latino Behavioral Health System (LBHS) represents a culturally informed community-academic collaboration that includes agencies focused on mental health, addictions, behavioral health within community health centers, and social rehabilitation; the Yale University Department of Psychiatry; and the Connecticut Department of Mental Health and Addiction Services. The core mission of the LBHS is to expand and enhance the provision of recovery-oriented, and culturally and linguistically appropriate, services to the monolingual Spanish-speaking community in parts of South Central Connecticut. This article outlines the rationale and need for such a collaboration to meet the needs of an underrepresented and underserved ethnic minority group. The process by which these entities came together to develop and successfully implement systemic strategies is described in the context of 2 overarching priorities: (a) workforce development, and (b) access to services. The authors also highlight lessons learned that have informed the decision-making process since the inception of the LBHS, and future directions to ensure that it is prepared to meet changing consumer needs and systemic priorities. (PsycINFO Database Record

Understanding Health Disparities Through the Eyes of Community Members: a Structural Competency Education Intervention

While there is wide recognition that social inequalities result in health disparities for segments of the US population [1], inclusion of information about health disparities and methods to address disparities are irregularly addressed in medical education [2]. Hansen and Metzl argue that political and economic structures directly impact health disparities through their effect on patient presentations and ability to work within the healthcare delivery system. They have strongly recommended that medical professionals develop “structural competency” in order to provide effective care [3]. Several residency programs have reported structural competency education interventions, teaching about the concept more broadly [4] or with a more specific intervention [5, 6]. Previously reported broad-based structural compentency interventions involved medical residents and faculty discussing these issues together [4]. Our challenge was to educate trainees about the effects of community structures on patients without having teachers who had a firsthand understanding of the myriad forces acting upon people living in economically disadvantaged neighborhoods [7].

The Biopsychosocial Formulation

Psychiatrists evaluate patients with complicated presentations and in the course of providing care must consider an ever-expanding array of available treatment options. In order to be effective, the psychiatrist must be able to understand their patients across biological, psychological, and sociocultural dimensions and use this understanding to guide treatment. IMG physicians may face particular challenges in adapting to this approach and so may gain from learning to assess and describe patients in a standardized manner that does not presuppose expertise in any specific biological approach, psychological tradition, or sociocultural context. This chapter presents an approach to the teaching of biopsychosocial formulation through a step-by-step process. Each dimension of the biopsychosocial formulation is discussed and attention is drawn to principles that may inform an approach to its teaching. While this approach is suitable for teaching resident physicians from all nationalities, emphasis is placed on the psychological and cultural formulation, which may be of particular salience to IMG physicians.

Novel Brief Cultural Psychiatry Training for Residents

Cultural sensitivity is crucial for optimal mental health outcomes. In particular, differing expectations can interfere with the delivery of quality care when clinicians and patients do not share the same background and belief systems. Cultural influences are linked to health disparities and the providers’ attitudes in the clinical encounter. Thus, education in cultural sensitivity should include experiences to help learners become aware of unconscious stereotypes, as well as understanding the impact of social and cultural influences on health outcomes [1–3]. There are multiple teaching approaches and cross-cultural curricular designs that address attitudes, knowledge, and skills [4]. The most comprehensive approach, grounded in the social sciences, uses the trainee’s awareness of their own cultural background to teach them how to respond effectively to their patient’s issues that involve culture and ethnicity [5]. We developed a curriculum using experiential learning as the main teaching approach [6]. Residents were the teachers, also addressing the need for trainees to acquire teaching skills [7]. In this paper, we describe the design and implementation of an innovative cultural psychiatry curriculum.