G. Eric Jarvis

The Social Causes of Psychosis in North American Psychiatry: A Review of a Disappearing Literature

Objective: To review the North American literature with respect to the role of social factors in the etiology of psychosis, including schizophrenia. Method: Relevant publications were identified through a search of MEDLINE from 1966 to 2006. Identified studies and articles had to originate in Canada or the United States to be included in the review. Articles written prior to 1966 were identified by cross-referencing bibliographies and reference lists. Articles were considered relevant if they discussed ethnoracial or other social factors as being causal or contributing to the development of psychosis or schizophrenia. Results: The relation between the etiology of psychosis and such social factors as poverty, migration, and racial discrimination has been neglected in the North American psychiatric literature for the last 40 years. In Canada and the United States, there is a dearth of research on these issues: the study of social causes of psychosis has been replaced by a focus on the clinical encounter, in which clinician bias is presumed to be responsible for widespread misdiagnosis of psychosis in minority (mainly African-American) populations. The reasons for neglecting social causes of psychosis in the North American psychiatric literature are obscure but may have to do with the rise of genetic–biological paradigms in recent decades. Conclusions: The neglect of social causes of psychosis in the North American psychiatric literature has been coincident with an increase in scholarly concern among European clinicians and researchers. Careful reading of the European literature may reveal helpful avenues for future investigation in the North American context. In addition, drawing on social science literature and methods may help to clarify mechanisms underlying poverty, migration, and racial discrimination that contribute to psychosis in vulnerable individuals and groups.

Training clinicians in cultural psychiatry: a Canadian perspective.

ObjectivesThe authors summarize the pedagogical approaches and curriculum used in the training of clinicians in cultural psychiatry at the Division of Social and Transcultural Psychiatry, McGill University.MethodWe reviewed available published and unpublished reports on the history and development of training in cultural psychiatry at McGill to identify the main orientations, teaching methods, curriculum, and course content. Student evaluations of teaching were reviewed. The training strategies and curriculum are related to the larger social context of Canadian society including the history of migration, current demography, and policies of multiculturalism.ResultsThe McGill program includes core teaching, clinical rotations, an intensive summer program, and annual Advanced Study Institutes. The interdisciplinary training setting emphasizes general knowledge rather than specific ethnocultural groups, including: understanding the cultural assumptions implicit in psychiatric theory and practice; exploring the clinician’s personal and professional identity and social position; evidence-based conceptual frameworks for understanding the interaction of culture and psychopathology; learning to use an expanded version of the cultural formulation in DSM-IV for diagnostic assessment and treatment planning; and developing skills for working with interpreters and culture-brokers, who mediate and interpret the cultural meaning and assumptions of patient and clinician.ConclusionAn approach to cultural psychiatry grounded in basic social science perspectives and in trainees’ appreciation of their own background can prepare clinicians to respond effectively to the changing configurations of culture, ethnicity, and identity in contemporary health care settings.

Religious Practice and Psychological Distress: The Importance of Gender, Ethnicity and Immigrant Status

The present study examined the relationship between religious practice and psychological distress in a culturally diverse urban population to explore how religious affiliation, gender, ethnicity, and immigrant status affect this relationship. Data were drawn from a study of health care utilization in Montreal. A stratified community sample of 1485 yielded four religious groups: Protestant (n = 205), Catholic (813), Jewish (201), and Buddhist (150), and a group with no declared religion (116). The sample was composed of five ethnocultural groups: Anglophone Canadian-born, Francophone Canadian-born, Afro-Caribbean, Vietnamese, and Filipino immigrants. Psychological distress was assessed with the 12-item version of the General Health Questionnaire (GHQ). Religious involvement was measured with three items: 1) declared religion; 2) frequency of attendance at religious meetings; and 3) frequency of religious rituals performed at home. Multiple regression models examined the relationship of religious practice to distress, controlling for sociodemographic variables including ethnicity. Overall, attendance at religious services was associated with a lower GHQ score. Attendance at religious services also was inversely related to psychological distress for females, Protestants, Catholics, Filipinos, and Afro-Caribbeans; but not for males, Buddhists or Jews. Religious practice at home was not associated with level of distress for any group. The ‘no declared religion’ group had the highest mean GHQ score of all the groups. Results confirm the association between attendance at religious services and lower levels of distress, but reveal ethnospecific and gender effects indicating the need to understand the impact of religious practice on mental health in social and cultural context.

The Process of Cultural Consultation

In this chapter, we describe the process of cultural consultations in terms of the specific steps from intake and triage, through interviewing and clinical data collection, to case formulation, communication of recommendations, and follow-up. We provide sufficient detail about the actual process to guide others wishing to set up similar services. The CCS team works within the framework of the cultural formulation introduced with DSM-IV, to identify ways that cultural background and current contexts interact to shape the manifestations of illness, its course, and potential interventions. The aim is to complement standard psychiatric evaluation by focusing on social and cultural dimensions that may be less familiar and that tend to get less attention in routine care. The CCS consultants use models drawn from cultural psychiatry and psychology, cognitive behavioral therapy, family systems theory, and ecosocial systemic approaches that emphasize the social embedding of illness experience as well as gender, racialized identity, and ethnicity. Cases are formulated in terms of the interplay of personal and social meanings and dynamics that include interactions with families, communities, health care and systems. While the consultations use psychiatric diagnostic categories, they also explore the personal and social meanings of symptoms and include a broader problem list of social predicaments as well as sources of resilience and potential strategies for healing and recovery. The cultural formulation brings together psychiatric and cultural expertise in an integrated assessment and recommendations for more effective patient care.

High rates of psychosis for black inpatients in Padua and Montreal: different contexts, similar findings.

ObjectiveThis study tested the hypothesis that despite differences in setting, specifically in Padua or Montreal, black psychiatric inpatients will have higher rates of assigned diagnosis of psychosis than their non-black counterparts.MethodsData on psychotic patients admitted to the psychiatry ward were extracted from records of general hospitals in Padua and Montreal. Logistic regression analyses were conducted separately for each site to determine the relation between being black and receiving a diagnosis of psychosis, while controlling for sex and age.ResultsMost black patients at both sites received a diagnosis of psychosis (76% in Padua and 81% in Montreal). Being black was independently and positively associated with being diagnosed with psychosis compared to patients from other groups.ConclusionsBlack patients admitted to psychiatry, whether in Padua or Montreal, were more likely to be assigned a diagnosis of psychosis than were other patients.

Changing Psychiatric Perception of African-Americans With Affective Disorders

Abstract This article explored the origins and implications of the underdiagnosis of affective disorders in African-Americans. MEDLINE and old collections were searched using relevant key words. Reference lists from the articles that were gathered from this procedure were reviewed. The historical record indicated that the psychiatric perception of African-Americans with affective disorders changed significantly during the last 200 years. In the antebellum period, the mental disorders of slaves mostly went unnoticed. By the early 20th century, African-Americans were reported to have high rates of manic-depressive disorder compared with whites. By the mid-century, rates of manic-depressive disorder in African-Americans plummeted, whereas depression remained virtually nonexistent. In recent decades, diagnosed depression and bipolar disorder, whether in clinical or research settings, were inexplicably low in African-Americans compared with whites. Given these findings, American psychiatry needs to appraise the deep-seated effects of historical stereotypes on the diagnosis and treatment of African-Americans.

Cultural Consultation in General Hospital Psychiatry

Cultural consultation in general hospital settings is complicated by time pressure to discharge patients, constrained physical space for interviewing, difficulty accessing language interpreters, and severe illness of the patients. Despite these challenges, cultural consultation in the general hospital can bring essential diagnostic expertise to bear on difficult cases, in addition to language interpretation and understanding of severe symptoms (self-harm, psychosis) in cultural context. At all times, careful consideration must be given to potential medical causes of symptoms. Suggested strategies for conducting cultural consultation in general hospital settings include: working with the referring clinical team to resolve problems of time pressure and inadequate interviewing space; inquiring before the consultation about the patient’s language proficiency; allowing sufficient time to interview patients who speak a different language or are from a different culture; initially focusing on matters that are most important to the patient, such as upcoming refugee hearings, work and financial problems, and family members who are enduring unsafe conditions; adopting a respectful, nonjudgmental clinical stance; and working with families, community members, and cultural mediators to give context to symptoms and behaviors. While the challenges of cultural consultation in general hospital settings are formidable, seemingly minor interventions can significantly influence patient diagnosis, care, and outcome.

Transatlantic variation in the attributed etiology of psychosis

Background: Differences in transatlantic perception of psychosis have been reported in the historical psychiatric literature. Aims: This study aims to determine if articles in the American Journal of Psychiatry (AJP) are more likely to attribute biological factors to the etiology of psychosis than those of the British Journal of Psychiatry (BJP). Methods: A systematic MEDLINE search for articles in the AJP and BJP from 2005 to 2007 identified 360 abstracts with psychosis and etiology-related words. Chi-square analyses were used to test differences in the proportion of attributed biological or psychosocial etiology of psychosis in each journal. Results: A greater proportion of abstracts (83/87) in the AJP attributed biological etiology of psychosis (χ2 = 12.33, df = 1, p < 0.001), while a greater proportion in the BJP (16/44 abstracts) attributed psychosocial etiology (χ2 = 19.76, df = 1, p < 0.001). Conclusions: The AJP tends to publish biomedical explanations of psychosis, while the BJP shows a relative preference for psychosocial theories.