Addressing Health Equity and Racism Through a Hispanic Psychiatry Fellowship.

The scarcity of bilingual psychiatrists, as well as appropriate mental health services for populations with limited English proficiency, has led to inequitable health outcomes. A fellowship program was developed, which draws from a clinical model staffed by bilingual (Spanish-English) professionals from racial-ethnic minority groups, to address access to care and the structural determinants of health. This new Hispanic Psychiatry Fellowship focuses on health inequality and racism in policy and leadership, clinical care for Spanish-speaking patients, cultural psychiatry, recovery, forensics, substance use, and education. This column describes the program's development, first 2 years of implementation, and feasibility indicators for use in creating similar programs.

Adapting the Cultural Formulation Interview for the Military.

OBJECTIVE: U.S. military service members, veterans, and their families increasingly seek care from providers with limited knowledge of military culture. The 16-item core DSM-5 Cultural Formulation Interview (CFI) was designed to integrate cultural factors into assessment and treatment of mental disorders. Although the CFI was designed for use with all patients, it is unknown whether the CFI adequately assesses military culture. The authors describe a methodology to determine the need for specific CFI versions and how to create a version for use with persons affiliated with the military. METHODS: Published articles on cultural competence in the military were systematically reviewed. Cultural domains were abstracted from each article, inductively coded, and hierarchically organized for assessment against the core CFI. A military CFI was created with additional implementation instructions, questions, and probes when the core CFI was inadequate for eliciting relevant cultural domains. RESULTS: Sixty-three articles were included. Coding revealed 22 military culture domains, of which only five would be elicited in the core CFI without additional guidance. Twelve of 16 questions in the core CFI required additional instructions, five benefited from question edits, and 10 needed additional probing questions. On the basis of these results, the authors crafted a military version of the CFI for service members, veterans, and their families. CONCLUSIONS: The military CFI for clinicians assesses aspects of military culture that are not comprehensively evaluated through the core CFI. The development process described in this article may inform the creation of other versions when the core CFI does not comprehensively assess cultural needs for specific populations.

A Study of a Cultural Competence and Humility Intervention for Third-Year Medical Students.

OBJECTIVE: This study evaluates the effectiveness of a cultural competence and humility intervention for third-year medical students by assessing changes in clinical evaluation assessments in patient encounters. METHODS: This study examines the effect of a 1-h educational intervention on cultural competence and cultural humility for third-year medical students. Clinical assessments during observed patient encounters are compared in the clerkship before and after the intervention. The intervention adapts a previously studied cultural competence didactic and emphasizes cultural humility practices. Change in scores from the intervention cohort (clinical year 2019-2020) is compared to a pre-intervention cohort (2018-2019). RESULTS: Students who completed the intervention demonstrate greater clinical competency in "relating to patients in a respectful, caring, empathetic manner" as assessed by supervising physicians compared with pre-intervention cohort students (2.7% difference in earning top two scores in subsequent clerkship, P value 0.05, Cramer's V 0.04). Greater clinical competencies were also found in the intervention students compared with pre-intervention students in the domains "demonstrates accountability, contribution and commitment to patient care" and "develops insightful, focused, pertinent questions based on clinical scenarios" (3.8% difference in earning top two scores in subsequent clerkship, P value 0.01 and 5.1% difference, P-value 0.003 with Cramer's V of 0.05 and 0.06, respectively). CONCLUSIONS: Educational interventions to improve cultural competence and cultural humility are important during clinical years to shape future physicians. Our study suggests that brief interventions may improve medical students' clinical competencies. A future study with a more robust intervention is expected to yield more substantial results.

Telehealth for rural diverse populations: telebehavioral and cultural competencies, clinical outcomes and administrative approaches.

Rural health care settings are challenged to provide timely and evidence-based care, particularly for culturally diverse patients with behavioral health disorders. Telepsychiatry and telebehavioral health improve access to care and leverage scarce resources. This scoping review from January 2000 - July 2019 was conducted to see if the literature had data for two related the research questions, "What are the components of culturally competent, telepsychiatric clinical care, and what approaches have clinicians and systems taken to implement and evaluate it?" The review focused on key words in four concept areas: (I) competencies; (II) telehealth in the form of telepsychiatry, telebehavioral or telemental health; (III) culture; and (IV) health. It was done in accordance with the six-stage scoping review process in PubMed/Medline and other databases. The screeners reviewed the full-text articles for final inclusion based on inclusion (mesh of the key words) and exclusion (e.g., need for only, skills abstractly discussed) criteria. From a total of 1,118 papers, the authors found 44 eligible for full text review and found 7 papers directly relevant to the concepts. Few studies specifically discuss skills and competencies of both telehealth and cultural factors. Many organizations are attending to cultural competencies and approaches to care, but there are no specific competencies that integrate telepsychiatry or telebehavioral health with culture. Existing telepsychiatric (i.e., video, social media, mobile health) and one set telebehavioral health competencies included cultural component, including use of interpreters and language matters. Administrative adjustments are suggested to promote culturally competent care by telehealth via clinical, educational, quality improvement, program/system evaluation, and other (e.g., finance and reimbursement) interventions. More structured research is needed on development, implementation and evaluation of combined competencies in rural settings.

Caring for Families Separated by Changing Immigration Policies and Enforcement: A Cultural Psychiatry Perspective.

Recent changes in U.S. immigration policies and enforcement have precipitated a 300% rise in arrests and planned deportations. Although some family members face deportation, other family members may have state-sanctioned status. Such mixed status puts hundreds of thousands of families at risk of forced separation and associated mental health problems. Building on cross-cultural work with refugee families and other groups and on work with families separated by parental incarceration, the authors provide recommendations to guide clinicians working with families who are separated or who fear separation. Mental health problems among separated families can in part be addressed through identifying the origins of distress, elucidating family structures and roles, strengthening communication practices, linking with legal and economic resources, and facilitating decision making through distress reduction.

Training on the DSM-5 Cultural Formulation Interview improves cultural competence in general psychiatry residents: A pilot study.

The objective of this study was to assess whether a 1-hour didactic session on the DSM-5 Cultural Formulation Interview (CFI) improves the cultural competence of general psychiatry residents. The main hypothesis was that teaching adult psychiatry residents a 1-hour session on the CFI would improve cultural competence. The exploratory hypothesis was that trainees with more experience in cultural diversity would have a greater increase in cultural competency scores. Psychiatry residents at a metropolitan, county hospital completed demographics and preintervention questionnaires, were exposed to a 1-hour session on the CFI, and were given a postintervention questionnaire. The questionnaire was an adapted version of the validated Cultural Competence Assessment Tool . Paired samples t tests compared pre- to posttest change. Hierarchical linear regression assessed whether pretraining characteristics predicted posttest scores. The mean change of total pre- and posttest scores was significant ( p = .002), as was the mean change in subscales Nonverbal Communications ( p < .001) and Cultural Knowledge ( p = .002). Demographic characteristics did not predict higher posttest scores (when covarying for pretest scores). Psychiatry residents' cultural competence scores improved irrespective of previous experience in cultural diversity. More research is needed to further explore the implications of the improved scores in clinical practice.

Training on the DSM-5 Cultural Formulation Interview Improves Cultural Competence in General Psychiatry Residents: A Multi-site Study.

OBJECTIVE: The authors assessed whether a 1-h didactic session on the DSM-5 Cultural Formulation Interview (CFI) improves cultural competence of general psychiatry residents. METHODS: Psychiatry residents at six residency programs completed demographics and pre-intervention questionnaires, were exposed to a 1-h session on the CFI, and completed a post-intervention questionnaire. Repeated measures ANCOVA compared pre- to post-intervention change. Linear regression assessed whether previous cultural experience predicted post-intervention scores. RESULTS: Mean scores on the questionnaire significantly changed from pre- to post-intervention (p < 0.001). Previous cultural experience did not predict post-intervention scores. CONCLUSIONS: Psychiatry residents' cultural competence scores improved with a 1-h session on the CFI but with notable limitations.

Educating psychiatry residents about cultural aspects of care: a qualitative study of approaches used by U.S. expert faculty.

BACKGROUND/OBJECTIVE: Almost no literature compares current approaches to teaching cultural issues across U.S. psychiatry residency programs; the authors addressed this comparison. METHODS: The authors administered semistructured interviews of 20 instructors with substantial experience in the teaching of cultural issues in U.S. psychiatry residency programs, regarding the content, teaching techniques, institutional context, and evaluation of their curricula over time. RESULTS: Approaches varied according to the local populations served and the background of the instructors, all of whom were either cross-trained in social sciences and humanities or were themselves ethnic, racial, or sexual minorities. Common themes emerged, including the use of experiential approaches, the lack of integration of cultural issues into clinical supervision or courses on other topics, and the absence of formal course evaluation. DISCUSSION: Findings indicate a need for integration of cultural concepts into a variety of settings throughout residency, for development of faculty who are cross-trained in social sciences and humanities, and for curriculum-evaluation strategies.

Culturally informed child psychiatric practice.

Child and adolescent psychiatrists are already serving an increasing population of culturally and ethnically diverse patients and families in their practices and in different agency settings. This article discusses adaptations to practice that enable child and adolescent psychiatrists to address the diverse clinical and cultural needs of this emerging population. Special attention is given to work in psychotherapy and in agency settings where diverse children and youth are found in large numbers.

Using non-feature films to teach diversity, cultural competence, and the DSM-IV-TR outline for cultural formulation.

OBJECTIVE: Feature films have been used for teaching in psychiatry for many years to demonstrate diagnoses, but the use of documentary and instructional films in resident and staff cultural competence training have not been extensively written about in the medical and psychological literature. This article will describe the films that have been used by the authors and suggest methods for their use in cultural competence and diversity training. METHODS: A literature search was done using MEDLINE and PsychINFO and the authors were asked to describe their teaching methods. RESULTS: One article was found detailing the use of videotapes as a stimulus but not for cultural competence education, and two articles were found documenting the use of The Color of Fear as a stimulus for the discussion of racism. However, many educators use these films all across the country for the purpose of opening discussion about racism. CONCLUSION: Documentary, instructional, and public service announcements can be useful in teaching culturally competent assessment and treatment.

Mental health disparities, diversity, and cultural competence in medical student education: how psychiatry can play a role.

OBJECTIVE: The authors review recent developments in healthcare policy, including eliminating disparities in mental healthcare, increasing diversity in the healthcare workforce, and cultural competence. Following a discussion of the Liaison Committee on Medical Education (LCME) standards, as they relate to disparity, cultural competence, and diversity, the authors discuss an action plan describing the role of psychiatry in addressing these issues. METHODS: Key policy documents are reviewed for disparities, cultural competence, and diversity in healthcare and then in mental health specifically. RESULTS: Important developments in healthcare policy regarding these areas have occurred. CONCLUSION: Psychiatry can play a vital role in addressing disparities, cultural competence, and diversity in medical student education.

A psychiatric residency curriculum about Asian-American issues.

Asian Americans constitute the third-largest and the fastest-growing minority group in the United States, with a population of 10.2 to 11.9 million in Census 2000. It is a heterogeneous group that includes at least 43 ethnic subgroups with different languages and dialects, immigration patterns, and religious beliefs; varying socioeconomic status; and different traditional patterns of seeking health care. These social and cultural variables affect Asian Americans' help-seeking behaviors, development of psychiatric disorders, manifestation of psychiatric symptoms, treatment strategies, compliance, and outcomes. This article reviews experiences of Asian Americans relevant to their mental health, including migration patterns to the United States, socioeconomic status, and cultural variables. It proposes educational objectives in the assessment and treatment of Asian-American patients that are essential for the training of psychiatric residents. In particular, it addresses special considerations in implementation of a psychiatric curriculum directed to the care of Asian-American psychiatric patients.