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

When Multispecies Ethnography Encounters a Shelter-Based Clinic: Uncovering Ecological Factors for Cultural Psychiatry

Through a longstanding collaboration, psychiatrists and anthropologists have assessed the impact of sociocultural context on mental health and elaborated the concept of culture in psychiatry. However, recent developments in ecological anthropology may have untapped potential for cultural psychiatry. This paper aims to uncover how "ecologies" inform patients' and clinicians' experiences, as well as their intersubjective relationships. Drawing on my ethnography with Jerome, a carriage driver who became my patient in a shelter-based psychiatric clinic, and on anthropological work about how psychic life is shaped ecologically, I describe how more-than-human relationality and the affordances of various places-a clinic and a stable-influenced both Jerome's well-being and my perceptions as a clinician. I also explore how these ecologies shaped our different roles, including my dual roles as psychiatrist and ethnographer. In the discussion, I define ecological factors, describe their implications for clinical practice, and suggest how they could be integrated into DSM's cultural formulation.

The Cultural Formulation Interview in Case Formulations: A State-of-the-Science Review

The publication of the 16-item Cultural Formulation Interview (CFI) in DSM-5 has initiated a robust line of international scholarship on whether patients and clinicians find it feasible, acceptable, and useful in different practice settings. Studies have routinely concluded that the CFI improves rapport when clinicians use it with patients, though less attention has been focused on how clinicians use information from the CFI in clinical tasks or case formulations. This state-of-the-science review describes the development of the CFI and uses a specific methodology, the state-of-the-art review, to analyze peer-reviewed studies reporting how clinicians have used information from the CFI in clinical tasks, namely diagnostic and treatment planning. Twelve studies met inclusion criteria, with 10 indicating that the CFI was helpful for these tasks. All studies emphasized that the CFI can help clinicians understand the social contexts of patients' lives. The article concludes with an agenda for future research, such as exploring how preexisting conceptions of culture influence clinical decision making and determining how the CFI affects case formulations.

The fragility of truth: Social epistemology in a time of polarization and pandemic

This essay introduces a thematic issue of Transcultural Psychiatry presenting selected papers from the 2022 McGill Advanced Study Institute in Cultural Psychiatry on "The Fragility of Truth: Social Epistemology in a Time of Polarization and Pandemic." The COVID-19 pandemic, political polarization, and the climate crisis have revealed that large segments of the population do not trust the best available knowledge and expertise in making vital decisions regarding their health, the governance of society, and the fate of the planet. What guides information-seeking, trust in authority, and decision-making in each of these domains? Articles in this issue include case studies of the dynamics of misinformation and disinformation; the adaptive functions and pathologies of belief, paranoia, and conspiracy theories; and strategies to foster and maintain diverse knowledge ecologies. Efforts to understand the psychological dynamics of pathological conviction have something useful to teach us about our vulnerability as knowers and believers. However, this individual psychological account needs to be supplemented with a broader social view of the politics of knowledge and epistemic authority that can inform efforts to create healthy information ecologies and strengthen the civic institutions and practices needed to provide well-informed pictures of the world as a basis for deliberative democracy, pluralism, and co-existence.

Gender-affirming care in the assessment and treatment of psychosis risk: Considering minority stress in current practice and future research

INTRODUCTION

Although research has documented the marked disparities in rates of psychosis-spectrum diagnoses in various socially marginalized populations, there is limited research addressing the needs of gender expansive individuals in the context of psychosis-spectrum illnesses using a minority stress lens. As clinical high-risk for psychosis (CHR-p) assessment and treatment becomes accessible to increasingly diverse populations, there is a need for clinicians to demonstrate greater clinical competency working with individuals across diverse social backgrounds and identities.

METHODS

We examined rates of gender expansive (GE) patients seeking evaluation at an urban-based CHR-p clinic and compared the diagnostic profile of GE individuals to cisgender patients. Post-hoc analyses were conducted on clinical variables with significant differences between the cisgender and GE groups.

RESULTS

The proportion of GE patients seeking evaluation increased from 2017 (9.3%) to 2021 (16.7%). Compared to cisgender youth, GE patients had significantly higher depressive, social anxiety, borderline personality disorder symptoms, higher levels of suicidality and non-suicidal self-injurious behaviour, and lower role functioning. Gender identity was predictive of suicidality controlling for social anxiety, borderline symptoms, and role functioning.

CONCLUSIONS

We review implications for CHR-p treatment and discuss ways to integrate minority stress theory and gender-affirming practices into coordinated specialty care for CHR-p patients.

Algorithmic fairness in precision psychiatry: analysis of prediction models in individuals at clinical high risk for psychosis

BACKGROUND

Computational models offer promising potential for personalised treatment of psychiatric diseases. For their clinical deployment, fairness must be evaluated alongside accuracy. Fairness requires predictive models to not unfairly disadvantage specific demographic groups. Failure to assess model fairness prior to use risks perpetuating healthcare inequalities. Despite its importance, empirical investigation of fairness in predictive models for psychiatry remains scarce.

AIMS

To evaluate fairness in prediction models for development of psychosis and functional outcome.

METHOD

Using data from the PRONIA study, we examined fairness in 13 published models for prediction of transition to psychosis (n = 11) and functional outcome (n = 2) in people at clinical high risk for psychosis or with recent-onset depression. Using accuracy equality, predictive parity, false-positive error rate balance and false-negative error rate balance, we evaluated relevant fairness aspects for the demographic attributes 'gender' and 'educational attainment' and compared them with the fairness of clinicians' judgements.

RESULTS

Our findings indicate systematic bias towards assigning less favourable outcomes to individuals with lower educational attainment in both prediction models and clinicians' judgements, resulting in higher false-positive rates in 7 of 11 models for transition to psychosis. Interestingly, the bias patterns observed in algorithmic predictions were not significantly more pronounced than those in clinicians' predictions.

CONCLUSIONS

Educational bias was present in algorithmic and clinicians' predictions, assuming more favourable outcomes for individuals with higher educational level (years of education). This bias might lead to increased stigma and psychosocial burden in patients with lower educational attainment and suboptimal psychosis prevention in those with higher educational attainment.

An Intersectional Approach to Ethnoracial Disparities in Pathways to Care Among Individuals With Psychosis in Coordinated Specialty Care

Importance

Intersecting factors of social position including ethnoracial background may provide meaningful ways to understand disparities in pathways to care for people with a first episode of psychosis.

Objective

To examine differences in pathways to care by ethnoracial groups and by empirically derived clusters combining multiple factors of social and clinical context in an ethnoracially diverse multisite early-intervention service program for first-episode psychosis.

Design, Setting, and Participants

This cohort study used data collected on individuals with recent-onset psychosis (<2 years) by clinicians with standardized forms from October 2013 to January 2020 from a network of 21 coordinated specialty care (CSC) programs in New York State providing recovery-oriented, evidence-based psychosocial interventions and medications to young people experiencing early psychosis.

Exposures

Ethnoracial group and other factors of social position (eg, insurance status, living situation, English fluency, geographic region) intersecting with first-contact experiences (ie, type of first service, referral source, and symptoms at referral).

Main Outcomes and Measures

Outcome measures were time from onset to first contact, first contact to CSC, and onset to CSC.

Results

The total study sample consists of 1726 individuals aged 16 to 30 years and included 452 women (26%), 1263 men (73%), and 11 (<1%) with another gender enrolled in the network of CSC programs. The total sample consisted of 153 Asian (9%), 599 Black (35%), 454 Latinx (26%), and 417 White individuals (24%). White individuals had a significantly shorter time from onset to first contact (median [IQR], 17 [0-80] days) than Asian (median [IQR], 34 [7-94] days) and Black (median [IQR], 30 [1-108] days) individuals but had the longest period from first contact to CSC (median [IQR], 102.5 [45-258] days). Five distinct clusters of individuals emerged that cut across ethnoracial groups. The more disadvantaged clusters in terms of both social position and first-contact experiences had the longest time from onset to first contact, which were longer than for any single ethnoracial group.

Conclusions and Relevance

In this cohort study of individuals with recent-onset psychosis, time-to-treatment outcomes differed by ethnoracial group and by empirically derived clusters combining multiple factors of social and clinical context. The examination of disparities in durations to treatment through an intersectional, ethnoracial lens may improve understanding of the inequities resulting from the various intersecting factors that may compound delays in treatment initiation.

From Womb to Neighborhood: A Racial Analysis of Social Determinants of Psychosis in the United States

The authors examine U.S.-based evidence that connects characteristics of the social environment with outcomes across the psychosis continuum, from psychotic experiences to schizophrenia. The notion that inequitable social and economic systems of society significantly influence psychosis risk through proxies, such as racial minority and immigrant statuses, has been studied more extensively in European countries. While there are existing international reviews of social determinants of psychosis, none to the authors' knowledge focus on factors in the U.S. context specifically-an omission that leaves domestic treatment development and prevention efforts incomplete and underinformed. In this review, the authors first describe how a legacy of structural racism in the United States has shaped the social gradient, highlighting consequential racial inequities in environmental conditions. The authors offer a hypothesized model linking structural racism with psychosis risk through interwoven intermediary factors based on existing theoretical models and a review of the literature. Neighborhood factors, cumulative trauma and stress, and prenatal and perinatal complications were three key areas selected for review because they reflect social and environmental conditions that may affect psychosis risk through a common pathway shaped by structural racism. The authors describe evidence showing that Black and Latino people in the United States suffer disproportionately from risk factors within these three key areas, in large part as a result of racial discrimination and social disadvantage. This broad focus on individual and community factors is intended to provide a consolidated space to review this growing body of research and to guide continued inquiries into social determinants of psychosis in U.S. contexts.

When the law influences medical practice: Potential impact of the Bouchard-Lebrun ruling on the forensic unit of the Malartic Psychiatric Hospital in Northern Quebec, Canada

The attribution of criminal responsibility in the context of substance intoxication is a matter of controversy in forensic psychiatry. In 2011, the Supreme Court of Canada ruled that Tommy Bouchard-Lebrun was guilty in the straightforward case of a crime committed while in a state of substance-induced psychosis by an individual without a history of mental disorder. However, the ruling may since have served as a precedent also for settling cases where an offence is committed while in a certain state of intoxication and where there is much more diagnostic uncertainty. The goal of our research was to study the impact of the Bouchard-Lebrun Supreme Court decision on rates of criminal responsibility judgements and toxic psychosis diagnosis in the context of such cases. Applying a time-trend ecological study design, we conducted a chart review of every patient treated at the forensic unit of the Malartic Psychiatric Hospital in northern Quebec in the short periods pre- and post-ruling. We then determined the proportion of patients judged not criminally responsible and the proportion diagnosed with substance-induced psychosis. We ran chi-squared tests on the two sets of dichotomous variables. In the period following the Bouchard-Lebrun ruling, a statistically significant decrease was observed in the proportion of individuals judged not criminally responsible, as was a statistically significant increase in the proportion of individuals diagnosed with substance-induced psychosis. The findings suggest that the Bouchard-Lebrun ruling may have had an impact on subsequent forensic psychiatry decision-making and treatment at the Malartic Hospital.

Assessment of psychiatrists' approaches regarding disclosure of psychiatric disorders to their patients: a qualitative study

Background: Diagnosis disclosure is the result of a shift in medical approaches from traditional paternalism to participatory and patient-centered decision making. Disclosure of psychiatric diagnosis remained uncommon and controversial. Giving information about psychiatric illnesses is very complicated, and it is affected by several factors. While clinical guidelines provide a clear pathway for treating patients, in practice, the treatment of patients is influenced by cultural and social factors. The aim of the current study was a qualitative assessment of psychiatrists’ approaches regarding the disclosure of psychiatric disorders to their patients.

Methods: The current study was conducted with a qualitative approach. The participants were purposefully selected psychiatrists from three medical universities in Tehran, Iran. The data gathered using the semi-structured interview method. Sixteen interviews with 14 psychiatrists were conducted. Data were analyzed using thematic analysis.

Results: Psychiatrists decide to disclose the diagnosis based on several factors. We summarized these factors in a central theme, passive situational decision making based on paternalism and displacement of responsibility. It has two subthemes, including "passive and situational decision making" and "paternalism and displacement of responsibility." Each theme presented by detailed quotations.

Conclusion: The results of this study showed that psychiatrists did not actively disclose the diagnosis name to patients. Diagnosis disclosure was influenced by several factors, such as the certainty about the diagnosis and the severity of the disease. This passive approach does not respect the patient's rights. The paternalistic nature of this approach mandates psychiatrists to consider themselves as the responsible perosn for their patients’ welfare.

Clinician's Subjective Experience in the Cross-Cultural Psychiatric Encounter

INTRODUCTION

The clinical encounter is still at the core of the psychiatric evaluation. Since the diagnostic process remains basically clinical in nature, several authors have addressed the complexity of the clinical reasoning process and highlighted the role played by intersubjective phenomena and clinician's feelings. Some recent studies have supported the view of a significant link between the clinician's subjective experience during the assessment and the diagnosis made. In a globalized world, this issue requires a careful reflection, since cultural differences may affect the intersubjective atmosphere of the encounter, which may indirectly influence the clinician's thinking.

METHODS

We used a previously validated instrument, named Assessment of Clinician's Subjective Experience (ACSE), to compare the clinician's subjective experience during the evaluation of Italian patients with the subjective experience of the same clinician during the assessment of foreign patients. The 2 patient groups (n = 42 each) were individually matched for known potential confounders (age, sex, categorical diagnosis, and clinical severity).

RESULTS

We found no significant differences in mean scores on all ACSE dimensions (tension, difficulty in attune-ment, engagement, disconfirmation, and impotence), which suggests that cultural diversity did not substantially affect the clinician's subjective experience. However, the lack of information about the native country and linguistic proficiency of about a quarter of foreign patients may have limited the possibility to detect subtle or specific differences, especially with regard to the clinician's empathic attunement.

CONCLUSIONS

Although further investigation is needed, our preliminary findings may have significant implications for the reflection upon the clinician's empathic experience as well as pragmatic consequences for the act of psychiatric diagnosis in the cross-cultural encounter.

Recovery and self-identity development following a first episode of psychosis

Purpose

The onset of psychosis typically develops during adolescence, a crucial period for beginning the transition from family to independence and developing a stable sense of self. Recovery amongst adolescents experiencing early onset psychosis has not yet been investigated with reference to its influence on self-identity. The purpose of this paper is to explore the impact living with early onset psychosis has on self-identity for adolescents in recovery.

Design/methodology/approach

A purposive sample of ten adolescents aged between 16 and 18 years from an Early Intervention Service in the Scottish National Health Service were recruited. All had experienced at least one episode of psychosis and were within three years of first contact with the service. Semi-structured interviews were adopted to capture adolescents’ perspectives concerning their experiences of recovery from psychosis and the impact on self-identity. All interviews were audio-recorded, transcribed and thematically analysed.

Findings

Qualitative analysis of adolescents’ accounts revealed how recovery from psychosis involves working with individual explanatory frameworks concerning uncertain identities and status ambiguity, a decrease in referent points and unfavourable social comparisons (emphasising loss, grief and self-criticism).

Research limitations/implications

Supporting adolescents experiencing early psychosis involves education, rebuilding relationships with self and others and providing access to psychotherapeutic interventions to aid self-identity development when needed.

Originality/value

The originality of this paper lies in the importance of identity, recovery, human reconnection, advocacy and community reintegration for adolescents experiencing psychosis. Public mental health campaigns to tackle the stigma surrounding psychosis are essential to assisting adolescents in developing their sense of self through their recovery journeys.

Assessing trauma in a transcultural context: challenges in mental health care with immigrants and refugees

The growing numbers of refugees and immigrants from conflict-prone areas settling throughout the world bring several challenges for those working in the mental health care system. Immigrants and refugees of all ages arrive with complex and nuanced mental health histories of war, torture, and strenuous migration journeys. Many of the challenges of addressing the health care needs for this growing population of immigrants and refugees are often unfamiliar, and thus practices to address these challenges are not yet routine for care providers and health care organizations. In particular, complex trauma can make mental health assessments difficult for health care organizations or care providers with limited experience and training in transcultural or trauma-informed care. Using a transcultural approach can improve assessment and screening processes, leading to more effective and high-quality care for immigrant and refugee families experiencing mental health disorders.

This paper presents findings from an assessment of current mental health services focusing on current practices and experiences with immigrant and refugee patients and families. The difficulties in developing shared understandings about mental health can hinder the therapeutic process; therefore, it is imperative to ensure an effective assessment right from the beginning, yet there is limited use of existing cultural formulation tools from the DSM-IV or DSM-5. The paper outlines current practices, approaches, challenges, and recommendations shared by mental health care providers and program leaders in addressing the mental health care needs of immigrants and refugees. The results from this study demonstrate that there are many challenges and inconsistencies in providing transcultural, trauma-informed care. Respondents emphasized the need for a thorough yet flexible and adaptive approach that allows for an exploration of differences in cultural interpretations of mental health. Our study concluded that ensuring a mindful, reflexive, transcultural, and trauma-informed health care workforce, and a learning environment to support staff with education, resources, and tools will improve the health care experiences of immigrants and refugees in the mental health care system.

Mapping the evidence on pharmacological interventions for non-affective psychosis in humanitarian non-specialised settings: a UNHCR clinical guidance

BACKGROUND

Populations exposed to humanitarian emergencies are particularly vulnerable to mental health problems, including new onset, relapse and deterioration of psychotic disorders. Inadequate care for this group may lead to human rights abuses and even premature death. The WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG), and its adaptation for humanitarian settings (mhGAP-HIG), provides guidance for management of mental health conditions by non-specialised healthcare professionals. However, the pharmacological treatment of people with non-affective psychosis who do not improve with mhGAP first-line antipsychotic treatments is not addressed. In order to fill this gap, UNHCR has formulated specific guidance on the second-line pharmacological treatment of non-affective psychosis in humanitarian, non-specialised settings.

METHODS

Following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, a group of international experts performed an extensive search and retrieval of evidence on the basis of four scoping questions. Available data were critically appraised and summarised. Clinical guidance was produced by integrating this evidence base with context-related feasibility issues, preferences, values and resource-use considerations.

RESULTS

When first-line treatments recommended by mhGAP (namely haloperidol and chlorpromazine) are not effective, no other first-generation antipsychotics are likely to provide clinically meaningful improvements. Risperidone or olanzapine may represent beneficial second-line options. However, if these second-line medications do not produce clinically significant beneficial effects, there are two possibilities. First, to switch to the alternative (olanzapine to risperidone or vice versa) or, second, to consider clozapine, provided that specialist supervision and regular laboratory monitoring are available in the long term. If clinically relevant depressive, cognitive or negative symptoms occur, the use of a selective serotonin reuptake inhibitor may be considered in addition or as an alternative to standard psychological interventions.

CONCLUSIONS

Adapting scientific evidence into practical guidance for non-specialised health workers in humanitarian settings was challenging due to the paucity of relevant evidence as well as the imprecision and inconsistency of results between studies. Pragmatic outcome evaluation studies from low-resource contexts are urgently needed. Nonetheless, the UNHCR clinical guidance is based on best available evidence and can help to address the compelling issue of undertreated, non-affective psychosis in humanitarian settings.

Diagnostic Emplotment in Q'eqchi' Maya Medicine

Medical diagnosis is a process of illness discrimination, categorization, and identification on the basis of careful observation and is central in biomedicine and many traditional medical systems around the world. Through a detailed analysis of several illness episodes and healer interviews among Maya communities in southern Belize, we observe that the diagnostic processes of traditional Q'eqchi' healers reflect patterns of narrative 'emplotment' that engage not simply the individual patient but also significant spiritual and cosmological forces. Three diagnostic techniques of the Q'eqchi' Maya healers are described and their connections to Maya concepts of personhood and cosmovision are presented. This research fosters an appreciation of how Indigenous knowledge systems shape clinical encounters and healing dramas, widening the spheres of clinical narrative co-construction and dialogue beyond the material and physical contexts implicit within Western clinical encounters.