A qualitative study about explanatory models of alcohol use disorder among patients and relatives in a Ugandan mental hospital.

BACKGROUND: Alcohol use disorder (AUD) is a major clinical problem in Uganda. Explanatory models (EMs) of illness are important as they have consequences for treatment. Clinicians´ knowledge about patients´ EMs can improve understanding of the latter´s perspectives and adapting treatments. There is a lack of African studies about EMs of AUD. The aim of this study was to explore EMs for AUD among hospitalized patients and their relatives at the alcohol and drug unit (ADU) at Butabika hospital in Uganda. METHODS: An adapted version of the Explanatory Model Interview Catalogue (EMIC) was used for interviews with ten patients and five relatives to investigate how both hospitalized patients with AUD and their relatives understand the disease. Data were analysed for themes with a qualitative content analysis and support of the software program, OpenCode 4.03. RESULTS: Five major themes were identified from the patient interviews: "Context promotes AUD"; "Alcohol is part of culture"; "Spiritual causes of AUD in the community"; "Help through Western medicine and religious sources is preferred" and "Social problems and stigmatization". Six major themes identified from the interviews with relatives were: "Numerous causes of drinking alcohol"; "Devastating consequences of drinking alcohol"; "Exploiting persons with AUD"; "Others' suffering"; "Relatives struggling for help" and "Suggested solutions". CONCLUSIONS: Patients' EMs of AUD included social and spiritual explanations. Alcohol is seen as an important part of the Ugandan culture among both patients and their relatives. The results indicate it is important in clinical contexts to investigate the EMs of the patients and relatives to individually tailor treatment interventions.

A qualitative analysis of the documentation of DSM-5 Cultural Formulation Interviews with non-native speaking patients in a Swedish mental health care setting.

Introduction: Cultural variety in expressed symptom presentations of mental health problems creates difficulties in transcultural diagnostic assessments. This emphasizes the need of culturally sensitive diagnostic tools like the Cultural Formulation Interview (CFI). Although the CFI is being implemented worldwide there is a lack of studies analyzing what kind of information it provides when used with new patients in routine psychiatric assessments, and how CFI information contributes to diagnostic evaluations. This study aimed to find out what information the CFI questions revealed when used with non-native Swedish speaking patients. We also wanted to understand how the CFI may facilitate identification of psychiatric diagnoses among these patients. Materials and methods: The CFI was used as part of a routine clinical psychiatric assessment in an outpatient clinic in Sweden. Interpreters were used in the consultations when needed. A qualitative thematic analysis was used to analyze the documented CFI answers from non-native speaking patients. Results: We found that the CFI information contained contextualized descriptions of dysfunction and current life conditions, as well as expressions of emotions, often described along with somatic terms. Discussion: Our results indicate that the narrative approach of the CFI, giving contextualized information about distress and functioning, can facilitate clinicians' identification of psychiatric symptoms when language, psychiatric terms and understandings are not shared between patient and clinician.

Interdisciplinary pain rehabilitation for immigrants with chronic pain who need language interpretation.

OBJECTIVE: To investigate outcomes in patients with chronic pain after participation in an interdisciplinary pain rehabilitation programme with language interpreters, and to investigate the outcomes in women and men separately. DESIGN: Prospective multi-centre cohort study. PATIENTS: Ninety-five patients in Sweden with chronic pain who have insufficient knowledge of the Swedish language. METHODS: Duration and intensity of pain, anxiety and depression, health-related quality of life and fear of movement were evaluated before and after the programme. Patients were compared with a reference group comprising Swedish-speaking patients participating in an ordinary interdisciplinary pain rehabilitation programme. RESULTS: Before the interdisciplinary pain rehabilitation programme with language interpreters, all variables except pain duration differed significantly to the detriment of the studied group. The studied group showed significant improvements after the interdisciplinary pain rehabilitation programme with language interpreters, with regards to pain intensity, depression and fear of movement. The reference group improved significantly for all variables. The women in the studied group showed significant improvements for the same variables as the whole group, while the men in the studied group did not improve in any of the variables. CONCLUSION: This study indicates that patients with chronic pain, and especially women, who have insufficient knowledge of Swedish seem to benefit from participating in an interdisciplinary pain rehabilitation programme with language interpreters. The result may be of value for the further development of rehabilitation programmes with language interpreters.

[Post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) - a clinical update of knowledge]. / Posttraumatiskt stressyndrom (PTSD) och komplex PTSD (CPTSD).

Post-traumatic stress disorder, PTSD, is a psychiatric diagnosis that describes a condition where one or more very traumatic events, that include life-threatening or extreme psychological stress, have left permanent traces of distress that induce sustained suffering.  In this clinical overview, we present current updates in diagnostic criteria and a new diagnosis of complex PTSD, and discuss the problems caused by the new PTSD diagnosis criteria partially differing in the DSM-5 and ICD-11 diagnostic manuals. Diagnostic challenges caused by symptom variations is discussed, as well as the high degree of comorbidity with other psychiatric and somatic illnesses. Combined forms of treatment that reduce both psychological PTSD and somatic symptoms is underscored, as well as the clinical value of early discovery of PTSD and treatment of comorbidity. Furthermore, the article illuminates knowledge about resilience and social support as protective factors.

[PTSD and Complex PTSD - Assessment, management and treatment]. / Utredning, handläggning och behandling av PTSD och CPTSD.

Post-traumatic stress disorder (PTSD) is a disruptive condition associated with great suffering. Fortunately, effective treatments are available. Assessment of children and adolescents with symptoms of PTSD is done within the child and adolescent mental health services. Adults are assessed in primary healthcare settings. In complex conditions with psychiatric comorbidity, assessment is conducted in specialist psychiatric services. Trauma-focused psychotherapy is the treatment of choice for both children and adults. Trauma-focused psychotherapy is also recommended for treating complex PTSD, despite a weaker evidence base. PTSD-specific treatment should normally be offered even in the presence of psychiatric comorbidities. Treatment of children and adolescents with PTSD and CPTSD is provided by child and adolescent mental health services. Adults can receive treatment both in primary and secondary healthcare settings, depending on symptomatology and comorbidities.

Samis in the city. A qualitative study of mental health and well-being among Samis in Stockholm.

Indigenous people globally suffer from poorer health than majority populations. For the Sami, the indigenous people living in the north of Norway, Sweden, Finland and Russia, physical health conditions seem to be comparable to the population in general, but there are concerns about mental health. Studies have shown a higher risk of suicide, especially for young men active in traditional reindeer herding in the north. There is less knowledge about the mental health of Samis that have migrated to the cities. In this study, we interviewed 25 Samis, recruited through convenience sampling in the Stockholm area, about their perceptions of health and well-being, the importance of the Sami background and culture, their views of mental health services and the need of adapting them to Sami needs. Throughout the process, the researchers collaborated closely with the Stockholm Sami Association, in an approach of participatory research. The interviews were analysed with thematic analysis. For the participants, a secure Sami identity and being treated with respect for their identity was seen as essential for mental health and well-being. Informants' emphasis on respect for their Sami identity and belonging can be seen as a call for restoration of basic human rights. Historical experiences, current harassments and political decisions affected their health. The informants wished caregivers to increase their knowledge of Sami history and traditions.

Migration background, eating disorder symptoms and healthcare service utilisation: findings from the Stockholm Public Health Cohort.

BACKGROUND: From a global perspective, eating disorders are increasingly common, probably because of societal transformation and improved detection. However, research on the impact of migration on the development of eating disorders is scarce, and previously reported results are conflicting. AIMS: To explore if eating disorder symptom prevalence varies according to birth region, parents' birth region and neighbourhood characteristics, and analyse if the observed patterns match the likelihood of being in specialist treatment. METHOD: This study uses data from a large population-based health survey (N = 47 662) among adults in Stockholm, Sweden. A general linear model for complex samples, including adjustment for gender and age, was used to explore self-reported eating disorder symptoms. Odds ratios were calculated for individual symptoms. RESULTS: Eating disorder symptoms are substantially more common in individuals born abroad, especially for migrants from a non-European country. This holds true for all surveyed symptoms, including restrictive eating (odds ratio 5.5, 95% CI 4.5-6.7), compensatory vomiting (odds ratio 6.1, 95% CI 4.6-8.0), loss-of-control eating (odds ratio 2.6, 95% CI 2.3-3.1) and preoccupation with food (odds ratio 2.3, 95% CI 1.9-2.8). Likewise, symptoms are more common in individuals with both parents born abroad and individuals living in districts with a high percentage of migrant residents. A gap exists between district-level symptom scores and the likelihood of being in specialist eating disorder treatment. CONCLUSIONS: These findings call for oversight of current outreach strategies, and highlight the need for efforts to reduce stigma and increase eating disorder symptom recognition in broader groups.

Training in cultural psychiatry: Translating research into improvements in mental health care for migrants.

This special issue of Transcultural Psychiatry on training in cultural psychiatry discusses translating research into improvements in mental health care for refugees and migrants. This topic is timely because, in addition to a global increase in migration, the number of forcibly displaced people is growing rapidly due to war and conflicts. We know that migrants, particularly refugees, are at increased risk of psychiatric disorders, including psychotic disorders and post-traumatic stress. Despite this, there is evidence of major disparities in care for minorities, migrants, and refugees. The gap between needs related to mental health care for migrants, refugees, and minority groups and available services points to the need to improve accessibility and adapt systems, services, and interventions. Health professionals have a key role in ensuring the quality of care. Their capacity to cope with new challenges depends on their competence, knowledge, skills, and attitudes toward their patients' needs. Mental health professionals need training in working with cultural diversity and structural competence to understand, treat, and support migrant and refugee patients-and to respond to racial discrimination. Mental health care services need to reduce barriers to providing adequate resources, including supporting skills training for mental health professionals. Hopefully, this thematic special issue will motivate further research, discussion, and sharing of local experience and pedagogical methods in this vital field.

Are all children treated equally? Psychiatric care and treatment receipt among migrant, descendant and majority Swedish children: a register-based study.

AIMS: Underutilisation of mental health services among migrant youth has been demonstrated repeatedly, but little is known about potential discrepancies in terms of treatment receipt for those who do reach services. This study examines the type and level of care received among migrant children and descendants of migrants, particularly investigating disparities in treatment receipt given a specific diagnosis. METHODS: We used register data of the total population aged 6-17 years in Stockholm, followed from 2006 to 2015, comprising 444 196 individuals, categorised as refugees, non-refugee migrants, descendants of migrants and Swedish-born. To identify recommended treatments for specific diagnoses we used official clinical guidelines. We report logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) of diagnosis receipt, treatment provision and level of care where a diagnosis was first registered. RESULTS: Migrant children had a lower likelihood of receiving a wide range of psychiatric diagnoses, including mood disorder (OR 0.58; 95% CI 0.52-0.64), anxiety disorder (OR 0.62; 95% CI 0.57-69) and neurodevelopmental disorder (OR 0.59; 95% CI 0.55-0.63). Moreover, when these diagnoses were set, migrant children had a lower likelihood of receiving the recommended treatments for these conditions compared to the majority individuals with the same diagnosis (OR of receiving psychotherapy for anxiety disorder and depression: 0.71; 95% CI 0.62-0.95 and 0.50; 95% CI 0.33-0.75, respectively; OR for receiving ADHD-medication: 0.49; 95% CI 0.43-0.54). CONCLUSIONS: Migrant children risk underdiagnosis of various mental health conditions, and, when reaching mental health services, risk not receiving the optimal care available.

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

BACKGROUND: Culture 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. METHOD: We 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. RESULTS: The 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). CONCLUSIONS: The 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 REGISTRATION: ISRCTN51527289 , 30/07/2019. The trial was retrospectively registered.

Could the DSM-5 Cultural Formulation Interview Hold Therapeutic Potential? Suggestions for Further Exploration and Adaptation Within a Framework of Therapeutic Assessment.

The Cultural Formulation Interview (CFI), included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, is a person-centered instrument for systematically appraising the impact of cultural factors in psychiatric assessment. A number of key areas in the future development of the CFI have been identified in order to ensure further clinical uptake. In this paper, we suggest that applying a Therapeutic Assessment (TA) approach in using the CFI-i.e., framing the interview in a way that gives primacy to its self-transformative potential by explicitly focusing on those issues that are seen as the most urgent, relevant, and meaningful by the patient-could prove helpful in alleviating patients' suffering beyond what is achieved by merely collecting relevant cultural information that may inform diagnosis and subsequent treatment interventions. The TA methodology has been designed as a collaborative approach to psychological assessment in which the assessment procedure itself is meant to induce therapeutic change. This is achieved by explicitly focusing on the particular questions and queries that patients have about themselves with respect to their mental health problems or psychosocial well-being; these questions are then allowed to guide the assessment process and the interpretation of the findings. We suggest a number of potential modifications to the related Outline for Cultural Formulation and to the CFI content that could strengthen a TA-inspired focus. With this paper, we do not claim to offer a definitive integration of the TA approach in using the CFI but hope to further the discussion of a therapeutic potential of the instrument.

Mental health service use among migrant and Swedish-born children and youth: a register-based cohort study of 472,129 individuals in Stockholm.

PURPOSE: Migrant children underutilize mental health services (MHS), but differences according to age, reason for migration, type of problem, and time have not been thoroughly analyzed. We aimed to explore utilization of MHS among migrant children and youth and to study if the hypothesized lower utilization could be explained by fewer neurodevelopmental assessments. METHODS: A cohort of the population aged 0-24 years in Stockholm, comprising 472,129 individuals were followed for maximum 10 years, between January 1, 2006 and December 31, 2015. We categorized individuals as accompanied refugee migrants, unaccompanied refugee migrants and non-refugee migrants, or Swedish-born. We used survival and logistic analyses to estimate rates of utilization of MHS. RESULTS: Migrant children and youth utilized less MHS than the majority population, with hazard ratios ranging from 0.62 (95% CI: 0.57; 0.67) to 0.72 (95% CI: 0.69; 0.76). Refugee and non-refugee children utilized less mental health care than their Swedish peers, apart from the youngest refugees (0-10 years) who had similar utilization as Swedish-born. The lower rates were partly explained by all migrant youths' lower risk of being diagnosed with a neurodevelopmental condition. Time in Sweden had a major impact, such that unaccompanied refugee minors had a higher utilization in their first 2 years in Sweden (OR: 3.39, 95% CI: 2.96; 3.85). CONCLUSION: Migrant youth use less MHS compared with native-born peers, and this is partly explained by fewer neurodevelopmental diagnoses. Strengthening the awareness about unmet needs, and the referring capacity by professionals in contact with migrant children could help reduce barriers to care.

Cross-cultural training program on mental health care for refugees - a mixed method evaluation.

BACKGROUND: Refugees tend to have a higher risk of mental ill-health and use mental health services less than the native-born population during their first 10 years in Sweden. Intercultural interactions between refugees and mental health professionals have been described as challenging. Cross-cultural training is proposed as one way to improve care for refugees. Evaluations of such training outcomes are sparse. The overall aim of this study was to evaluate Comprehensive Cross-Cultural Training for mental health care professionals in Stockholm, and to assess training outcomes for participants' perceived knowledge regarding mental health and care for newly arrived refugee patients, asylum seekers and undocumented refugees. In addition, we analysed the dimensionality of the pre- and post-training questionnaires used. METHODS: An embedded mixed-method design was applied. We used pre-and post-training questionnaires (n = 248) and conducted six focus group discussions (FGDs) with mental health professionals after training. Quantitative data was analysed by t-tests and factor analysis, qualitative data was analysed using thematic content analysis. RESULTS: Participants experienced gained knowledge and new perspectives in all aspects covered in the training. Training led to participants restructuring their existing knowledge. Those who had reported experience of refugee patients and working with interpreters pre-training in the past month, had higher ratings of perceived knowledge. Post-training, there were no significant changes in perceived knowledge between those with, and those without, experience of refugee patients and working with interpreters. Factor analysis resulted in 3 factors for the pre-training questionnaire, explaining 71% of the covariance, and 4 factors for the post-training questionnaire, explaining 78% of the covariance. Findings from the post-training FGDs, revealed that refugee patients were described as challenging. Also, that training promoted empathy towards refugees and strengthened participants' professional role. CONCLUSIONS: This cross-cultural training contributed to knowledge development and attitude changes. It was valuable regarding care providers' professional role. Additional outcomes of the training were that participants not only gained knowledge about refugee mental health care but also restructured their existing knowledge.

Perceived barriers to care for migrant children and young people with mental health problems and/or neurodevelopmental differences in high-income countries: a meta-ethnography.

OBJECTIVES: To develop conceptual understanding of perceived barriers to seeking care for migrant children and young people (aged 0-25 years) with mental health problems and/or neurodevelopmental differences in high-income countries. DESIGN: Qualitative evidence synthesis using meta-ethnography methodology. We searched four electronic databases (Medline, PsycINFO, Global Health and Web of Science) from inception to July 2019 for qualitative studies exploring barriers to care (as perceived by migrant communities and service providers) for migrant children and young people in high-income countries with neurodevelopmental differences and/or mental health problems. The quality of included studies was explored systematically using a quality assessment tool. RESULTS: We screened 753 unique citations and 101 full texts, and 30 studies met our inclusion criteria. We developed 16 themes representing perceived barriers to care on the supply and demand side of the care-seeking process. Barriers included: stigma; fear and mistrust of services; lack of information on mental health and service providers lacking cultural responsiveness. Themes were incorporated into Levesque et al's conceptual framework of patient-centred access to healthcare, creating a version of the framework specific to migrant children and young people's mental health and neurodevelopmental differences. CONCLUSIONS: This is the first qualitative evidence synthesis on barriers to care for mental health problems and/or neurodevelopmental differences in migrant children and young people in high-income countries. We present an adapted conceptual framework that will help professionals and policy-makers to visualise the complex nature of barriers to care, and assist in improving practice and designing interventions to overcome them. Similar barriers were identified across study participants and migrant populations. While many barriers were also similar to those for children and young people in general populations, migrant families faced further, specific barriers to care. Interventions targeting multiple barriers may be required to ensure migrant families reach care.

Interventions to increase migrants' care-seeking behaviour for stigmatised conditions: a scoping review.

BACKGROUND: Despite availability of effective treatments, migrants in high-income countries seek care for conditions associated with stigma to a lower extent than the rest of the population. We conducted a scoping review to map the literature on interventions to increase migrants' care-seeking behaviour in high-income countries for stigmatised conditions. Main body of the abstract: We searched 15 electronic databases and journals, hand-searched references and citations, to identify studies on interventions to increase migrants' care-seeking in high-income countries for stigmatised conditions. We applied language restrictions for English and Swedish, and searched the full time period up to 5 July 2019. Our primary outcome of interest was care utilisation. RESULTS: 5447 records were identified in the literature searches. We identified 16 eligible studies, all from North America, that reported interventions to increase migrants' care-seeking behaviour for hepatitis B (n = 1) and mental health (n = 15). Three approaches were identified: health communication (n = 10), support groups (n = 2), and primary care-based approaches (n = 4). There was a general trend towards community-based interventions tailored to individual migrant groups. Significant gaps were identified in the literature, including studies conducted in Europe and studies including men or children. Furthermore, the choice of study designs introduced significant bias that prevented accurate conclusions on intervention effectiveness. CONCLUSION: The available evidence on interventions to increase migrants' in high-income countries care-seeking behaviour for stigmatised conditions is limited in scope and quality. Future research, using reliable study designs, is needed to fill the remaining gaps and to boost the scope and reliability of the evidence.

An Internet Based Intervention for Adults With Autism Spectrum Disorder-A Qualitative Study of Participants Experiences.

Background: Adults with autism spectrum disorder face several barriers to accessing evidence-based care, including difficulties in communicating needs, social anxiety or in traveling to a health care unit. In recent years, several forms of internet-based treatments have shown to be effective for a variety of psychiatric conditions. Internet-based treatment alternatives allow convenient and flexible formats, and therefore have the potential to increase access to health care for individuals with autism spectrum disorder. However, knowledge about how internet-based treatment features may suit the needs of individuals with autism is limited. The aim of this study was to explore the participant experiences of an internet-based intervention for adults with autism spectrum disorder. The primary focus of the investigation was on autism-specific needs in relation to the features unique to the online format. Methods: In this qualitative study, semi-structured telephone interviews were conducted with 14 participants who had completed a text-based internet-based intervention for adults with autism spectrum disorder. We used an inductive approach and analyzed the data using qualitative content analysis. Results: Five main categories were identified: (1) implications of the online format, (2) the fixed non-individualized model, (3) therapist interaction, (4) interacting with other participants, and (5) making use of the treatment content. Overall, participants appreciated the availability and that they could work on their treatment independent of time or location. Among those participating in group-based chat-sessions with the other participants, it was considered a generally positive experience. Furthermore, most participants felt safe and relaxed in relation to the therapist and appreciated the text-based format. However, several participants felt that the format and content of the treatment was not sufficiently adapted to their individual life situation. Conclusion: In conclusion, this internet-based treatment constitutes an accessible and energy-saving treatment alternative for adults with autism. Further, integrating group-based components seems feasible in an otherwise individual internet-based treatment for individuals with autism. However, group-based components do require a clear purpose and rationale. Future studies should develop and evaluate treatment adaptations tailored to individual needs.

Psychiatric care use among migrants to Sweden compared with Swedish-born residents: a longitudinal cohort study of 5 150 753 people.

BACKGROUND: To investigate differences in psychiatric care use over time between Swedish born and those born abroad who migrate to Sweden. METHODS: Population-based cohort study analysing linked population and health registers, following individuals born 1944-1990 from 1 January 2005 to 31 December 2016. Time-stratified survival analysis using Cox regression estimated time to psychiatric care use. Population included 5 150 753 individuals with 78.1% Swedish born. Migrant status was coded as Swedish born or migrant. Migrants were grouped by year of immigration and region of origin. The main outcome: psychiatric care use, defined as any psychiatric care; psychiatric inpatient or outpatient care; or use of psychotropics. RESULTS: Migrants arriving before 2005 had a higher use of any psychiatric care relative to Swedish born but migrants arriving 2005 onwards had lower use. Migrants from sub-Saharan Africa and Asia had a lower use of any psychiatric care during the first decade in Sweden whereas migrants from Middle East and North Africa had a higher use, driven by use of psychotropics. CONCLUSIONS: The lower use of psychiatric care during the first decade contrasts with higher use among migrants with a longer duration of stay. Psychiatric care use among migrants should be analysed multi-dimensionally, taking duration of stay, region of origin and type of care into account.

Patients' and clinicians' experiences of the DSM-5 Cultural Formulation Interview: A mixed method study in a Swedish outpatient setting.

This study is an evaluation of clinicians' and patients' experiences of the core Cultural Formulation Interview (CFI) in DSM-5. The CFI provides a framework for gathering culturally relevant information, but its final form has not been sufficiently evaluated. Aims were to assess the Clinical Utility (CU), Feasibility (F) and Acceptability (A) of the CFI for clinicians and patients, and to explore clinicians' experiences of using the CFI in a multicultural clinical setting in Sweden. A mixed-method design was applied, using the CFI Debriefing Instrument for Clinicians (N = 15) and a revised version of the Debriefing Instrument for Patients (N = 114) (DIC and DIP, scored from -2 to 2). Focus group interviews were conducted with clinicians. For patients (response rate 50%), the CU mean was 0.98 (SD = 0.93) and F mean 1.07 (SD = 0.83). Overall rating of the interview was 8.30 (SD = 1.75) on a scale from 0 and 10. For clinicians (response rate 94%), the CU mean was 1.14 (SD = 0.52), F 0.58 (SD = 0.93) and A 1.42 (SD = 0.44). From clinician focus-group interviews, the following themes were identified: approaching the patient and the problem in a new manner; co-creating rapport and understanding; and affecting clinical reasoning and assessment. Patients and clinicians found the CFI in DSM-5 to be a feasible, acceptable, and clinically useful assessment tool. The focus group interviews suggested that using the CFI at initial contact can help make psychiatric assessment patient-centred by facilitating patients' illness narratives. We argue for further refinements of the CFI.

Differences in psychiatric care utilisation among unaccompanied refugee minors, accompanied migrant minors, and Swedish-born minors.

PURPOSE: To better understand underutilisation of psychiatric care among migrant children, we compared utilisation of psychiatric care among unaccompanied refugee minors and accompanied migrant minors, with Swedish-born minors. METHODS: Using a large longitudinal database of linked national registers, we established a retrospective cohort of 1,328,397 people born 1984-1988 comparing minors born in Sweden to 2 Swedish-born parents (95.4%) to minors who had been arriving in Sweden between 2002 and 2011 with a permanent resident permit and were either unaccompanied refugee minors (0.4%), or accompanied migrant minors (4.0%). The outcome measures were different measures of psychiatric care including in- and outpatient care, and prescribed psychotropic medication. RESULT: Compared with the Swedish-born minors the unaccompanied refugee minors had a higher likelihood of utilisation of all psychiatric care except ADHD medication. However, compared with accompanied migrant minors, the Swedish-born minors had a higher likelihood of having utilised psychiatric care. CONCLUSION: Our study shows that during the first years of living in Sweden, there seems to be fewer barriers to psychiatric care for unaccompanied refugee minors compared to the accompanied migrant minors. There are a number of possible reasons for this including stronger ties with the Swedish society.

[Cultural and social variability need to be included in development of methods]. / All metodutveckling måste inkludera mångfaldsfrågor - Påfrestande exiltillvaro kan påverka resultat av behandling vid posttraumatisk stress.

Psychiatric treatment must be developed and adapted, as Sweden's population has become increasingly multicultural and many migrants are refugees from war and conflict areas. Methods and ways of working need to take account of cultural variation in the expression of symptoms and the fact that many refugees have experienced deeply traumatic events, such as torture and other violations of their human rights. Methods should be sensitive to patients' experiences, knowledge and social situation, and consider social determinants of health. Here we provide examples of evidence-based transcultural method development, with a particular focus upon adults and the treatment of posttraumatic stress disorder (PTSD). We also examine the cultural encounter as well as indicate areas in need of development.