International Medical Graduates in Psychiatry: Cultural Issues in Training and Continuing Professional Development.

A position paper developed by the Canadian Psychiatric Association's Education Committee and approved by the CPA's Board of Directors on August 15, 2016.

The University of Manitoba Psychiatry Toolkit: Development and Evaluation.

OBJECTIVE: The authors developed and measured the subsequent utilization of a web-based point-of-care information tool and meta-search filter, the University of Manitoba Psychiatry Toolkit, as well as conduct an evaluation of its impact on physicians' information seeking. METHODS: Evaluation entailed analysis of toolkit web page utilization data from user visits to the web-based toolkit, as well as an online survey distributed to psychiatrists and resident trainees to assess information gathering behaviors and attitudes regarding various sources of medical information. RESULTS: Electronic resources and colleagues were the preferred sources for gathering health information, while inadequate time and search skills were ranked as important barriers. Age and physician cadre influenced toolkit use. Majority of respondents used the Psychiatry Toolkit to answer a clinical question, and urgency of the clinical problem influenced their decision to use it. CONCLUSIONS: The Psychiatry Toolkit assists psychiatrists and residents in finding answers to clinical questions arising at point-of-care, helping enhance the ongoing educational needs of physicians.

Comparing gendered and generic representations of mental illness in Canadian newspapers: an exploration of the chivalry hypothesis.

PURPOSE: The 'chivalry hypothesis' posits that woman are treated more compassionately by the media when compared with men. To our knowledge, no research study has explored the chivalry hypothesis as applied to people with mental illness. As such, we set out to compare three types of newspaper articles, those that focus on (1) mental illness generically; (2) a woman with mental illness; and (3) a man with mental illness. METHODS: We conducted a content analysis of 1,168 newspaper articles relating to mental health over 6 months. We obtained articles through media retrieval software using various search terms. We read and coded articles for the presence or absence of themes and content. Frequency counts and proportions were generated for each theme, which were compared across the three types of articles using Chi-square tests. RESULTS: Generic articles were more positive than articles about individuals. They were significantly more likely to quote mental health experts, and have recovery, inadequate resources, and etiology as themes. Articles that depicted men were significantly more likely to have stigmatizing content and violence as themes. Articles depicting women were significantly more likely to quote mental health experts, discuss mental health interventions, and have recovery and inadequate resources as themes. CONCLUSION: The findings lend some support to the chivalry hypothesis, in as much as articles about women were significantly more positive. Articles about men were significantly more negative, though this may be partially accounted for by elevated rates of violent crime in men. Generic articles were the most extensively well informed.

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

We examined how the process of cultural formulation contributes to diagnostic assessment of patients with psychotic disorders at a specialized Cultural Consultation Service (CCS). Specifically, we investigated the reasoning process used to resolve uncertainty of psychotic disorder diagnosis in African immigrant patients referred to the CCS for assessment of possible psychotic disorder. Qualitative thematic analysis of 23 clinical case conference transcripts was used to identify clinicians' reasoning styles. Use of the CF appears to facilitate the emergence of a rule-governed reasoning process that involved three steps: (i) problematize the diagnosis of the intake 'psychosis' symptoms or behavior; (ii) elaborate explanations as to why the symptoms or behavior may or may not be psychosis; and (iii) confirm the diagnosis of psychosis or re-interpret as non-psychosis. Prototypes and exemplars drawn from previous experience in intercultural work featured prominently in clinicians' reasoning. Prototypes were crucial in diagnostic decision-making and appear to be important sources of both clinician expertise and bias, and may need to be targeted specifically in cultural competence training.

Building Resilience and Attachment in Vulnerable Adolescents: The Feasibility of a Virtually Delivered Group Intervention for Adolescents with Suicidal Ideation and Their Caregivers.

Background: The COVID-19 pandemic required many interventions to be conducted virtually. Building Resilience and Attachment in Vulnerable Adolescents (BRAVA) is a group intervention designed for adolescents and their caregivers to reduce adolescent suicidal ideation (SI). Objective: We aimed to adapt BRAVA for virtual delivery and evaluate its acceptability and feasibility. Methods: We conducted an 8-week pre-post trial between October and December 2020. Six adolescents and six primary caregivers were recruited from a pediatric hospital in Ontario, Canada. Families completed a virtual intake and exit assessment together and 6 weekly BRAVA group sessions separately. Satisfaction feedback was collected after each group session and during their exit, and clinical outcomes were collected at intake and exit. Weekly team meetings were conducted to gather clinician feedback. Results: The study uptake rate was 42.9% of eligible participants. There were no dropouts. Adolescent and caregiver attendance rates for group sessions were high (median = 6). Most youth (83.4%) and caregivers (66.7%) reported that the virtual process worked well. All caregivers (100%) agreed they would participate in a virtual group session again, compared with youth (50%). Providers approved of the virtual adaptation but identified potential improvements (e.g., manual content, safety procedures). Adolescent SI decreased significantly post-treatment (Mpre = 50.7, Mpost = 29.7, p = 0.002). Conclusions: Virtual delivery of BRAVA is acceptable and feasible and may help reduce SI in adolescents. Uptake, retention, and satisfaction were high for adolescents and caregivers. Feedback collected will improve BRAVA for future evaluations, including a randomized controlled trial.

A brief scale to assess hospital doctors' attitudes toward collaborative care for mental health.

OBJECTIVE: Collaborative care may improve mental health management in hospital settings. However, no scales assess doctors' attitudes toward its 2 core components: mental health management by nonpsychiatric physicians and psychiatric consultation. Our objective was to develop and assess the reliability and validity of the Doctors' Attitudes Toward Collaborative Care for Mental Health (DACC-MH) Scale. METHOD: Fifteen items assessing doctors' attitudes toward management of mental health problems (10 items) and psychiatric consultation (5 items) were administered to 225 physicians and surgeons from a London hospital. Item responses were dichotomous (agree or disagree). Confirmatory factor analysis models were conducted using Mplus for dichotomous data to identify items for inclusion in the DACC-MH and to test the validity of the 2 hypothesized factors. Known-groups validity was tested by comparing scores of surgeons and physicians, as physicians have been shown to view mental health management and psychiatric consultation more favourably. RESULTS: The 8-item DACC-MH included a 4-item Attitudes Toward Management of Mental Health Problems factor (Cronbach's a = 0.65) and a 4-item Attitudes Toward Psychiatric Consultation factor (alpha = 0.67; overall scale alpha = 0.70). Model fit was good (chi2 = 12.7, df = 11, P = 0.31; Comparative Fit Index = 0.99; Tucker-Lewis Index = 0.99; root mean square error of approximation = 0.03) with all factor loadings of 0.46 or greater. As hypothesized, physician scores were significantly higher than surgeon scores on both subscales, indicating more positive attitudes toward management of mental health problems and psychiatric consultation. CONCLUSIONS: Preliminary evidence was found for the validity of the DACC-MH, which will facilitate efforts to evaluate readiness of doctors to engage in collaborative mental health care.

Family participation in treatment, post-discharge appointment and medication adherence at a Nigerian psychiatric hospital.

In low-income countries, clinicians must seek strategies to improve treatment adherence that are non-resource intensive and easily integrated into existing treatment structures. We conducted a prospective observational cohort study to investigate the relationship of family engagement in treatment during hospitalisation with post-discharge appointment and medication adherence in 81 patients from a Nigerian psychiatric hospital. After controlling for gender, diagnosis, mental state at discharge, and marital status, family involvement was significantly associated with appointment (P=0.047) but not medication adherence (P=0.590). Studies are needed to determine whether interventions based on engaging families in treatment can improve post-discharge adherence in this setting.

Perinatal depression in Nigeria: perspectives of women, family caregivers and health care providers.

BACKGROUND: Perinatal maternal depression is common and undertreated in many sub-Saharan African countries, including Nigeria. While culture shapes the social determinants and expression of depressive symptoms, there is a dearth of research investigating these processes in African contexts. METHODS: To address this gap, we conducted in-depth interviews with 14 women with perinatal depression, 14 of their family caregivers and 11 health providers, using the McGill Illness Narrative Interview as part of a larger trial of a stepped-care intervention. Interpretation of themes was guided by cultural constructivist and critical anthropological perspectives that situate perinatal depression in its complexity as a disorder that is embedded in webs of social relations and embodied practices. RESULTS: Study respondents used idioms of distress that identified perinatal conditions that consist of somatic, affective, cognitive and behavior symptoms found in depressive disorders. Respondents viewed mental health problems in the perinatal period as tied to sociomoral concerns over gender roles and women's position within the household. Conflict between women's effort to be assertive to address interpersonal problems, while needing to be seen as non-aggressive contributed to their distress. Causal explanations for depression included husband's lack of care, family problems, "spiritual attack", having a female child when a male child was desired, and not resting sufficiently after childbirth. Guilt about breaching social norms for women's conduct contributed to self blame, and feelings of shame. CONCLUSIONS: Clinical assessment and interventions as well as public health prevention strategies for perinatal depression in global mental health need to consider local social contexts and meanings of depression, which can be explored with narrative-based methods.

Using the cultural formulation to resolve uncertainty in diagnoses of psychosis among ethnoculturally diverse patients.

OBJECTIVE: The aim of the study was to assess the impact of systematic use of the DSM-IV-TR cultural formulation on diagnoses of psychotic disorders among patients of ethnic minority and immigrant backgrounds referred to a cultural consultation service (CCS) in Canada. METHODS: The study entailed a review of medical records and case conference transcripts of 323 patients seen in a ten-year period at the CCS to determine factors associated with change in the diagnosis of psychotic disorders by the CCS. Logistic regression analysis was used to identify variables associated with changes in diagnosis. RESULTS: A total of 34 (49%) of the 70 cases with an intake (referral) diagnosis of a psychotic disorder were rediagnosed as nonpsychotic disorders, whereas only 12 (5%) of the 253 cases with an intake diagnosis of a nonpsychotic disorder were rediagnosed as a psychotic disorder (p<.001). Major depression, posttraumatic stress disorder (PTSD), adjustment disorder, and bipolar affective disorder were the common disorders diagnosed with use of the cultural formulation. Rediagnosis of a psychotic disorder as a nonpsychotic disorder was significantly associated with being a recent arrival in Canada (odds ratio [OR]=6.05, 95% confidence interval [CI]=1.56-23.46, p=.009), being nonblack (OR=3.72, CI=1.03-13.41, p=.045), and being referred to the CCS by nonmedical routes (such as social work or occupational therapy) (OR=3.23, CI=1.03-10.13, p=.044). CONCLUSIONS: Misdiagnosis of psychotic disorders occurred with patients of all ethnocultural backgrounds. PTSD and adjustment disorder were misidentified as psychosis among immigrants and refugees from South Asia. Studies are needed that compare clinical outcomes of use of cultural consultation with outcomes from use of other cultural competence models.