Psychiatric Diagnostic Practice Research Articles

Impact on routine psychiatric diagnostic practice from implementing the DSM-5 cultural formulation interview: a pragmatic RCT in Sweden

BackgroundCulture and social context affect the expression and interpretation of symptoms of distress, raising challenges for transcultural psychiatric diagnostics. This increases the risk that mental disorders among migrants and ethnic minorities are undetected, diagnosed late or misdiagnosed. We investigated whether adding a culturally sensitive tool, the DSM-5 core Cultural Formulation Interview (CFI), to routine diagnostic procedures impacts the psychiatric diagnostic process.MethodWe compared the outcome of a diagnostic procedure that included the CFI with routine diagnostic procedures used at Swedish psychiatric clinics. New patients (n = 256) admitted to a psychiatric outpatient clinic were randomized to a control (n = 122) or CFI-enhanced diagnostic procedure (n = 134) group. An intention-to-treat analysis was conducted and the prevalence ratio and corresponding 95% confidence intervals (CI) were calculated across arms for depressive and anxiety disorder diagnoses, multiple diagnoses, and delayed diagnosis.ResultsThe prevalence ratio (PR) of a depressive disorder diagnosis across arms was 1.21 (95% CI = 0.83-1.75), 33.6% of intervention-arm participants vs. 27.9% of controls. The prevalence ratio was higher among patients whose native language was not Swedish (PR =1.61, 95% CI = 0.91-2.86). The prevalence ratio of receiving multiple diagnoses was higher for the CFI group among non-native speaking patients, and lower to a statistically significant degree among native Swedish speakers (PR = .39, 95% CI = 0.18-0.82).ConclusionsThe results suggest that the implementation of the DSM-5 CFI in routine psychiatric diagnostic practice may facilitate identification of symptoms of certain psychiatric disorders, like depression, among non-native speaking patients in a migration context. The CFI did not result in a reduction of patients with a non-definite diagnosis.Trial registrationISRCTN51527289, 30/07/2019. The trial was retrospectively registered.

Disrupted Dialogues: Exploring Misgendered Diagnoses and Experiences of Melancholia and Depression Through the Lens of Pericles and Contemporary Psychiatric Practice

ABSTRACT This article disrupts present-day readings of women’s experience of and diagnoses with depression by reading them in the light of the patriarchally inscribed experience of melancholia in the early modern period as explored in Shakespeare and Wilkins’ Pericles. It reads the paralleled experiences of Pericles and Marina and early modern proto-medical treatises in the light of contemporary psychiatric diagnostic practice and psychosocial research. It considers how norms, gendering, and privilege can affect the way an individual’s expression of their experience is read, received, diagnosed, and treated, as eroticised cures are laid against talking therapies in Pericles, and the gendered application of the labels of melancholia and depression and the gendered assumptions undergirding therapeutic interventions are probed. In so doing, it shows the value of reading early modern drama through a medical humanities lens to underline the biases which still have a measurable impact in mental health diagnostic settings today. The stark consequences of these biases for women emerge when these texts are brought into interdisciplinary and transhistorical dialogue. The early modern and present strands are pulled together by exploring how Pericles pushes back against the way gender can be leveraged to mistreat, exploit or silence.

Documenting diagnosis in child and adolescent mental healthcare: A content analysis of diagnostic statements in a psychiatric case register

Understanding clinical practice in relation to psychiatric diagnosis is important for identifying avenues for service improvement, developing clinically valid research methods and informing debate about prevailing diagnostic systems. Minimal research has explored psychiatric diagnostic practice by studying the diagnostic information present in clinical records. This study identifies, quantifies and descriptively analyses the range of contexts in which diagnostic terms appear in free-text child and adolescent clinical notes. Text segments containing a diagnostic term (N = 2993) were extracted from children’s electronic health records and subjected to content analysis. Segments were coded as indicating: definite diagnostic confirmations (49.4%), qualified diagnostic confirmations (6.4%), diagnostic queries/assessment (16.9%), definite diagnostic exclusions (3.1%), qualified diagnostic exclusions (2.2%), diagnostic status of another person (13.5%), or clinically irrelevant text (8.6%). Qualitative content analysis explored the linguistic patterns characterising these contexts of use. Results are considered in terms of their implications for service delivery, sociological analyses of psychiatric diagnosis, and the opportunities and challenges posed by applications of natural language processing techniques to electronic health records.

Our psychiatric future and the (bio)politics of Mental Health: dialogues with Nikolas Rose

Here we present the last of a series of four interviews with English sociologist Nikolas Rose. We explore central aspects of the recently published work entitled “Our Psychiatric Future: politics of Mental Health policies”, which has as background issues and problems that we consider absolutely relevant for facing the complex and difficult challenges posed to the implementation of Brazilian Public Health system and to the reform of Mental Health in our country. In this interview, we seek to discuss with the author: psychiatry as a (bio)politics; the ‘epidemics’ of mental disorders’; the role and consequences of psychiatric diagnostic practice in defining what is defined as mental disorder or illness; the use and abuse of psychiatric drugs in the contemporary; strengths and weaknesses of discursive psychiatric practices in ‘developed’ countries; limits and possibilities of users’ participation in Mental Health.

What use is a psychiatric diagnosis?

Current psychiatric diagnostic practice is usually based on groups of symptoms reported by patients which are compared with symptom clusters in recognized diagnostic classifications, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The number of psychiatric diagnoses has increased in each edition of DSM, which may not be in the best interest of those we treat. Some of the issues with increasing diagnostic categories include potential for overmedicalization, lack of scientific evidence relating to each diagnostic category, and clinician efforts to make a precise diagnosis too early when a more longitudinal assessment is necessary. Clinicians should be mindful of this in their practice and ensure that the unique life experience of each individual is considered in clinical encounters.

Transcultural issues in diagnostic process

Diagnostic systems and methods must respond to patients’ diversity in expressions of mental distress, social and cultural context and the meanings given to illness. Due to increasing migration and globalisation the challenge of considering diagnosis in the context of culture has become increasingly significant in Europe. And globalization has further led to changes in value systems and our awareness of patients with ethnic minority background.Over recent decades, there has been an increasing development of psychiatric diagnosing with nosological categorisation combined with multi-axial schemas. Diagnosis, besides identifying a disorder and distinguishing one disorder from another disorder - differential diagnosis, has also an aim to include an overall understanding of the patient's situation.We witness an upsurge in the attention paid to the cultural limitations to psychiatric diagnostic practice and treatment modalities. Guidelines for the psychiatric profession are in critical focus from a transcultural perspective. Some claim their universality independent of cultural context; others find cultural adaptation useful and necessary.Do the diagnoses and clinical and ethical guidelines give meaning in the cultural setting? Are they compatible with the cultural values of the therapist and those of the patient and the family? Several sources claim the biomedical paradigm for being Western with insufficient consideration of the socio-political context.The cultural formulation developed as part of DSM-IV and now DSM-5 is one model to support a systematic review of culture and context in psychiatric diagnosing.The paper will discuss the advantages and shortcomings of current diagnostic categories and guidelines vis-à-vis the universe of traumatized refugees with other ethnic backgrounds.URL:http://www.mariannekastrup.dk/Disclosure of interestThe author has not supplied his declaration of competing interest.

The meaning of pain: A cultural formulation of a Syrian woman in Sweden

Ethnography provides a method for psychiatric assessment to obtain an insight into the patient's culture, context, and life situation. The Outline for a Cultural Formulation (CF) is an ethnography-based, idiographic formulation intended to complement the multiaxial assessment in DSM-IV. Its contribution to routine clinical praxis will be discussed with reference to a case of a Syrian-born woman in Sweden. Using the CF in the clinical diagnostic process shifted understanding of the patient's suffering from a mainly somatic frame of reference to an emphasis on emotional and social aspects. The usefulness of ethnography in clinical psychiatric diagnostic practice is discussed.

GL.07 Dimensions or categories: what the new genetics tells us about neuropsychiatric disorders

Mirroring clinical practice, it has been conventional for psychiatric research, including the search for predisposing genes, to proceed under the assumption that schizophrenia and bipolar disorder are separate disease entities...

The Cultural Formulation: A Model to Combine Nosology and Patients’ Life Context in Psychiatric Diagnostic Practice

This article discusses the experience of adapting and applying the Outline for a Cultural Formulation in DSM-IV to the Swedish context. Findings from a research project on the Cultural Formulation highlight the value of combining psychiatric nosological categorization with an understanding of patients' cultural life context in order to increase the validity of categorization and to formulate individualized treatment plans. In clinical care practitioners need models and tools that help them take into account patients' cultural backgrounds, needs, and resources in psychiatric diagnostic practice. We present a summary of a Swedish manual for conducting a Cultural Formulation interview. The need for further development of the Cultural Formulation is also discussed.

Correcting biases in psychiatric diagnostic practice in Northwest Russia: Comparing the impact of a general educational program and a specific diagnostic training program

BackgroundA general education in psychiatry does not necessary lead to good diagnostic skills. Specific training programs in diagnostic coding are established to facilitate implementation of ICD-10 coding practices. However, studies comparing the impact of these two different educational approaches on diagnostic skills are lacking. The aim of the current study was to find out if a specific training program in diagnostic coding improves the diagnostic skills better than a general education program, and if a national bias in diagnostic patterns can be minimised by a specific training in diagnostic coding.MethodsA pre post design study with two groups was carried in the county of Archangels, Russia. The control group (39 psychiatrists) took the required course (general educational program), while the intervention group (45 psychiatrists) were given a specific training in diagnostic coding. Their diagnostic skills before and after education were assessed using 12 written case-vignettes selected from the entire spectrum of psychiatric disorders.ResultsThere was a significant improvement in diagnostic skills in both the intervention group and the control group. However, the intervention group improved significantly more than did the control group. The national bias was partly corrected in the intervention group but not to the same degree in the control group. When analyzing both groups together, among the background factors only the current working place impacted the outcome of the intervention.ConclusionEstablishing an internationally accepted diagnosis seems to be a special skill that requires specific training and needs to be an explicit part of the professional educational activities of psychiatrists. It does not appear that that skill is honed without specific training. The issue of national diagnostic biases should be taken into account in comparative cross-cultural studies of almost any character. The mechanisms of such biases are complex and need further consideration in future research. Future research should also address the question as to whether the observed improvement in diagnostic skills after specific training actually leads to changes in routine diagnostic practice.

A caution on the use of cut-points applied to screening instruments or diagnostic criteria

Although cut-points or threshold scores are commonly used in screening instruments as well as in psychiatric diagnostic practice, much is still to be learned about their functional characteristics. This study demonstrates that, for a cut-off of y items on a screening instrument, there is great variability in the identification of caseness between different combinations of y items. The results suggest that the use of cut-points is perhaps not as reliable as is sometimes thought.

Problems of diagnoses in family studies

This paper discusses applications of advances in psychiatric diagnostic practice to genetic research. Diagnostic misclassification and unreliability can lead to spurious conclusions about patterns of familial aggregation and co-aggregation of psychiatric disorders. Subject, occasion, information, observation and criterion variance are the major components of unreliability in diagnosis. Structured diagnostic criteria are useful for reducing errors; they may, however, lead to unjustified confidence due to their algorithmic and semi-quantitative format. Six misconceptions regarding such criteria are discussed. The choice of instruments and method of implementation must take into account the qualifications of interviewers and the need for blindness in the experimental design. A fundamental design decision in psychiatric genetic research is the choice between the family history or family study method. The costs and benefits of each method are examined. Finally, the psychiatric geneticist must face the problem of defining the ill phenotype. This is made difficult by the presence of phenocopies and the possibility that milder spectrum disorders and some symptom-free individuals may carry the genotype that underlies the phenotype of the more severe clinical form of the disorder.

Relationships of psychopathology to age, sex, ethnicity, education and marital status in state hospital patients

THE INCREASING use of symptom and behavior rating scales in clinical research during the past two decades has created a renewed respectability for descriptive psychiatry. This has led us back to a concern for directly observable manifestations, the phenomenology of mental illness.l-3 Rating scales such as the BPRS (Brief Psychiatric Rating Scale)4 and the IMPS (Inpatient Multidimensional Psychiatric Scale)5 have proven very useful in the field of psychopharmacology. Not only have they permitted quantitative evaluation of symptom change, but they have also provided a basis for description and classification of patients.6 The classification of patients solely on the basis of current symptom manifestations is a radical departure from usual psychiatric diagnostic practice in which history, etiology and sociocultural information enter into classificatory decisions. Although phenomenological description and classification have advantages, we must also recognize a growing body of evidence indicating that phenomenological differences are substantially related to personal, social and cultural variables.’ The significance of observed psychopathology may depend on the context of background factors within which it occurs. It is important that symptom rating scales, rather than clinical diagnoses, be used in evaluating the psychiatric relevance of background variables. Clinical diagnostic classification involves consideration of historical and sociocultural factors; thus certain built-in relationships are to be expected, whereas the use of quantitive rating scale profiles to describe psychopathology avoids most of this problem. In addition, well known problems related to the absence of clearly defined diagnostic criteria and consequent unreliability of clinical diagnoses are avoided. Although numerous variables are potentially interesting with respect to implications for manifest psychopathology, a relatively small number are almost universally considered