Symptom vs context: lessons learned from a large-scale implementation of the Cultural Formulation Interview

Mental health services in multicultural societies require culturally sensitive approaches to reduce health disparities. The Cultural Formulation Interview (CFI) is thought to enhance shared decision making and to facilitate culturally and contextually informed treatment. There is, however, little known regarding its implementability in large-scale psychiatric services. The current paper reports on (a) efforts to implement the CFI in a large organization for mental health services in the Netherlands, and (b) two studies that evaluated this implementation process and identified barriers to CFI adoption in clinical practice. Implementation of the CFI was facilitated by developing an online course, an advanced training of “team coaches”, (digital) resources, and integrating the CFI questions into the intake format. A preliminary evaluation revealed that the CFI was administered in only 13.2% of all intakes across the entire organization, with minimal utilization of training resources. Study 1 aimed to investigate how the CFI was perceived by clinicians and stakeholders. A survey of 150 clinicians found a great lack of familiarity with the CFI and its purpose. While 67% reported partial CFI use, 50% saw no added value, and 61% deemed it relevant only for ethnic minorities. Study 2 examined which patient and clinician variables were associated with adequate CFI use (i.e., correct documentation of the CFI information in initial intake reports). The sample consisted of 112 intakes of patients conducted by ten clinicians. Regression analysis showed a significant association between clinicians’ cultural competences and adequate CFI use, meaning that more culturally competent clinicians tended to generate better cultural assessments using the CFI. In addition, the CFI information was documented more adequately among patients who were unemployed at the time of assessment. In conclusion, implementation of the CFI requires a fundamental rethinking of the entire intake assessment, shifting it from a symptom-oriented approach towards a context- and person-centered one. Future trainings may benefit from embedding the CFI within a broader cultural competency training, rather than solely focusing on the CFI, which is currently the common practice

The attribution of Mental health Problems to Jinn:An explorative study in a Transcultural Psychiatric Outpatient clinic

FSW - Self-regulation models for health behavior and psychopathology - ou

Prevalence of mental disorders in refugees and asylum seekers: a systematic review and meta-analysis

Abstract Background Studies have identified high rates of mental disorders in refugees, but most used self-report measures of psychiatric symptoms. In this study, we examined the percentages of adult refugees and asylum seekers meeting diagnostic criteria for major depressive disorder (MDD), post-traumatic stress disorder, bipolar disorder (BPD), and psychosis. Methods A systematic literature search in three databases was conducted. We included studies examining the prevalence of MDD, post-traumatic stress disorder, BPD, and psychosis in adult refugees according to a clinical diagnosis. To estimate the pooled prevalence rates, we performed a meta-analysis using the Meta-prop package in Stata (PROSPERO: CRD42018111778). Results We identified 7048 records and 40 studies (11 053 participants) were included. The estimated pooled prevalence rates were 32% (95% CI 26–39%; I2 = 99%) for MDD, 31% (95% CI 25–38%; I2 = 99.5%) for post-traumatic stress disorder, 5% (95% CI 2–9%; I2 = 97.7%) for BPD, and 1% (95% CI 1–2%; I2 = 0.00%) for psychosis. Subgroup analyses showed significantly higher prevalence rates of MDD in studies conducted in low-middle income countries (47%; 95% CI 38–57%, p = 0.001) than high-income countries studies (28%; 95% CI 22–33%), and in studies which used the Mini-International Neuropsychiatric Interview (37%; 95% CI 28–46% p = 0.05) compared to other diagnostic interviews (26%; 95% CI 20–33%). Studies among convenience samples reported significant (p = 0.001) higher prevalence rates of MDD (35%; 95% CI 23–46%) and PTSD (34%; 95% CI 22–47%) than studies among probability-based samples (MDD: 30%; 95% CI 21–39%; PTSD: 28%; 95% 19–37%). Conclusions This meta-analysis has shown a markedly high prevalence of mental disorders among refugees. Our results underline the devastating effects of war and violence, and the necessity to provide mental health intervention to address mental disorders among refugees. The results should be cautiously interpreted due to the high heterogeneity

Assessment of explanatory models of mental illness: effects of patient and interviewer characteristics

Background: Explanatory models (EMs) refer to patients’ causal attributions of illness and have been shown to affect treatment preference and outcome. Reliable and valid assessment of EMs may be hindered by interviewer and respondent disparities on certain demographic characteristics, such as ethnicity. The present study examined (a) whether ethnic minority patients reported different EMs to ethnically similar interviewers in comparison with those with a different ethnicity, and (b) whether this effect was related to respondents’ social desirability, the perceived rapport with the interviewer and level of uncertainty toward their EMs. Methods: A total of 55 patients of Turkish and Moroccan origins with mood and anxiety disorders were randomly assigned to ethnically similar or dissimilar interviewers. EMs were assessed, using a semi-structured interview, across 11 different categories of causes. Results: Participants who were interviewed by an ethnically similar interviewer perceived interpersonal, victimization and religious/mystical causes as more important, whereas interviews by ethnically dissimilar interviewers generated higher scores on medical causes. These effects were not mediated by the perceived rapport with the interviewer, and social desirability had a modest impact on the results. Higher uncertainty among participants toward medical and religious/mystical causes seemed to be associated with greater adjustment in the report of these EMs. Conclusion: The findings have significant implications for interviewer selection in epidemiological research and clinical practice

The role of migration processes and cultural factors in the classification of personality disorders

Migrants and ethnic minorities are at risk of being under- and overdiagnosed with personality disorders (PDs). A culturally informed approach to the classification of PDs guides clinicians in incorporating migration processes and cultural factors, to arrive at a reliable and valid assessment of personality pathology. In this article, we provide a tentative framework to highlight specific interactions between personality disorders, migration processes, and cultural factors. It is argued that migration processes can merely resemble personality pathology, activate certain (latent) vulnerabilities, and aggravate pre-existing personality pathology. We propose that these migration processes can include manifestations of grief about the loss of pre-migratory psychosocial and economic resources, and the struggle to attain psychosocial and economic resources in the host culture. Moreover, several cultural dimensions are outlined that can either resemble or mask personality pathology. The term “culturally masked personality disorder” is coined, to delineate clinical cases in which cultural factors are overused or misused to rationalize behavioral patterns that are consistently inflexible, distressing, or harmful to the individual and/or significant others, lead to significant impairment, and exceed the relevant cultural norms. Additionally, the role of historical trauma is addressed in the context of potential overdiagnosis of personality disorders in Indigenous persons, and the implications of misdiagnosis in migrants, ethnic minorities, and Indigenous populations are elaborated. Finally, clinical implications are discussed, outlining various diagnostic steps, including an assessment of temperament/character, developmental history, systemic/family dynamics, migration processes, cultural dimensions, and possible historical trauma. </jats:p

sj-pdf-1-tps-10.1177_13634615211036408 - Supplemental material for The role of migration processes and cultural factors in the classification of personality disorders

Supplemental material, sj-pdf-1-tps-10.1177_13634615211036408 for The role of migration processes and cultural factors in the classification of personality disorders by Ardalan Najjarkakhaki and Samrad Ghane in Transcultural Psychiatry</p

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Supplemental material, sj-pdf-2-tps-10.1177_13634615211036408 for The role of migration processes and cultural factors in the classification of personality disorders by Ardalan Najjarkakhaki and Samrad Ghane in Transcultural Psychiatry</p

Developing a culturally sensitive mental health intervention for asylum seekers in the Netherlands: A pilot study

Introduction: This pilot study investigated asylum seekers’ needs and expectations in the mental health field to develop a culturally sensitive psychosocial intervention. Method: Participants were residents of a certain asylum-seekers centre in the Netherlands, with most of them from the Middle East crisis. Needs and expectations were identified using therapy expectations questionnaire (11 participants) and two focus groups (17 participants). Results: Participants associated mental health problems with post-migration stressors more often than with past traumatic experiences. Often, health problems were silenced due to shame, guilt, anxiety and the fear of negative stigma. Individuals and communities were limited in their ability to provide support for those suffering from psychosocial distress due to heavy stigma and the burden of multiple stressors. Conclusion: We underscore the importance of considering the local knowledge of mental health in developing emergency interventions and emphasise the need to reach beyond the trauma-focused approach to strengthen capacities within the community. Key implications for practice Developing a culturally sensitive mental health intervention for asylum seekers requires local knowledge of mental health issues Mental health interventions in emergencies should reach beyond the individualistic trauma-focused approach to address the whole context of forced displacement Because armed conflict often leads to a disruption of the social ecology of a community, mental health interventions should build on existing local support and services and strengthen capacities within the community

Prevalence of mental disorders in refugees and asylum seekers: a systematic review and meta-analysis

AbstractBackgroundStudies have identified high rates of mental disorders in refugees, but most used self-report measures of psychiatric symptoms. In this study, we examined the percentages of adult refugees and asylum seekers meeting diagnostic criteria for major depressive disorder (MDD), post-traumatic stress disorder, bipolar disorder (BPD), and psychosis.MethodsA systematic literature search in three databases was conducted. We included studies examining the prevalence of MDD, post-traumatic stress disorder, BPD, and psychosis in adult refugees according to a clinical diagnosis. To estimate the pooled prevalence rates, we performed a meta-analysis using the Meta-prop package in Stata (PROSPERO: CRD42018111778).ResultsWe identified 7048 records and 40 studies (11 053 participants) were included. The estimated pooled prevalence rates were 32% (95% CI 26–39%; I2= 99%) for MDD, 31% (95% CI 25–38%; I2= 99.5%) for post-traumatic stress disorder, 5% (95% CI 2–9%; I2 = 97.7%) for BPD, and 1% (95% CI 1–2%; I2= 0.00%) for psychosis. Subgroup analyses showed significantly higher prevalence rates of MDD in studies conducted in low-middle income countries (47%; 95% CI 38–57%, p = 0.001) than high-income countries studies (28%; 95% CI 22–33%), and in studies which used the Mini-International Neuropsychiatric Interview (37%; 95% CI 28–46% p = 0.05) compared to other diagnostic interviews (26%; 95% CI 20–33%). Studies among convenience samples reported significant (p = 0.001) higher prevalence rates of MDD (35%; 95% CI 23–46%) and PTSD (34%; 95% CI 22–47%) than studies among probability-based samples (MDD: 30%; 95% CI 21–39%; PTSD: 28%; 95% 19–37%).ConclusionsThis meta-analysis has shown a markedly high prevalence of mental disorders among refugees. Our results underline the devastating effects of war and violence, and the necessity to provide mental health intervention to address mental disorders among refugees. The results should be cautiously interpreted due to the high heterogeneity.</jats:sec

The Attribution of Mental Health Problems to Jinn: An Explorative Study in a Transcultural Psychiatric Outpatient Clinic

BackgroundAmong Muslim patients, a common cultural concept of distress is the notion that jinn may be the cause of mental health problems, especially in the presence of hallucinations.ObjectiveThis study examines the frequency with which this attribution style is manifest in a specific psychiatric outpatient population with a Muslim background.MethodsOf all patients registered at an outpatient clinic specialized in transcultural psychiatry, data were collected on folk belief, religion, hallucinations (if present), and medical diagnosis. Through a search in the electronic medical files, the notes made during the first contact and first psychiatric examination were screened for the keywords “evil eye,” “magic,” “voodoo,” and “jinn.” In addition, new eligible cases were accepted.ResultsFrom all 551 patients thus screened, 118 were eligible for participation. Of these, 49 (41.5%) were interviewed using a semi-structured questionnaire. Among them, 21 (43%) were positive that their psychiatric symptoms were caused by jinn, whereas 13 (27%) thought not, and 15 (31%) were in doubt. No less than 87.2% had experienced hallucinations during their lives. Among the relatively large proportion of eligible patients who did not participate (58.5%), many expressed a fear for stigmatization or metaphysical repercussions if they spoke about jinn.ConclusionThe phenomenon of attributing mental health symptoms to jinn was much more common in this population of Muslim patients than previously assumed. This underscores the need for proper knowledge of Muslim explanatory models of disease and for the use of culturally sensitive interviewing techniques in this population