Patient Perceptions of Illness Causes and Treatment Preferences for Obsessive-Compulsive Disorder: A Mixed-Methods Study.

Obsessive-compulsive disorder (OCD) is a condition with high patient morbidity and mortality. Research shows that eliciting patient explanations about illness causes and treatment preferences promotes cross-cultural work and engagement in health services. These topics are in the Cultural Formulation Interview (CFI), a semi-structured interview first published in DSM-5 that applies anthropological approaches within mental health services to promote person-centered care. This study focuses on the New York City site of an international multi-site study that used qualitative-quantitative mixed methods to: (1) analyze CFI transcripts with 55 adults with OCD to explore perceived illness causes and treatment preferences, and (2) explore whether past treatment experiences are related to perceptions about causes of current symptoms. The most commonly named causes were circumstantial stressors (n = 16), genetics (n = 12), personal psychological traits (n = 9), an interaction between circumstantial stressors and participants' brains (n = 6), and a non-specific brain problem (n = 6). The most common treatment preferences were psychotherapy (n = 42), anything (n = 4), nothing (n = 4), and medications (n = 2). Those with a prior medication history had twice the odds of reporting a biological cause, though this was not a statistically significant difference. Our findings suggest that providers should ask patients about illness causes and treatment preferences to guide treatment choice.

Clinical significance of psychotic-like experiences across U.S. ethnoracial groups.

BACKGROUND: Prevalence of psychotic-like experiences (PLEs) - reports of hallucinations and delusional thinking not meeting criteria for psychotic disorder - varies substantially across ethnoracial groups. What explains this range of PLE prevalence? Despite extensive research, the clinical significance of PLEs remains unclear. Are PLE prevalence and clinical severity differentially associated across ethnoracial groups? METHODS: We examined the lifetime prevalence and clinical significance of PLEs across ethnoracial groups in the Collaborative Psychiatric Epidemiology Surveys (N = 11 139) using the Composite International Diagnostic Interview (CIDI) psychosis symptom screener. Outcomes included mental healthcare use (inpatient, outpatient), mental health morbidity (self-perceived poor/fair mental health, suicidal ideation or attempts), and impairment (role interference). Individuals with outcome onsets prior to PLE onset were excluded. We also examined associations of PLEs with CIDI diagnoses. Cox proportional-hazards regression and logistic regression modeling identified associations of interest. RESULTS: Contrary to previous reports, only Asian Americans differed significantly from other U.S. ethnoracial groups, reporting lower lifetime prevalence (6.7% v. 8.0-11.9%) and mean number (0.09 v. 0.11-0.18) of PLEs. In multivariate analyses, PLE clinical significance showed limited ethnoracial variation among Asian Americans, non-Caribbean Latinos, and Afro-Caribbeans. In other groups, mental health outcomes showed significant ethnoracial clustering by outcome (e.g. hospitalization and role interference with Caribbean-Latino origin), possibly due to underlying differences in psychiatric disorder chronicity or treatment barriers. CONCLUSIONS: While there is limited ethnoracial variation in U.S. PLE prevalence, PLE clinical significance varies across U.S. ethnoracial groups. Clinicians should consider this variation when assessing PLEs to avoid exaggerating their clinical significance, contributing to mental healthcare disparities.

Religiosity and Stigmatization Related to Mental Illness Among African Americans and Black Immigrants: Cross-Sectional Observational Study and Moderation Analysis.

ABSTRACT: Stigma about mental illness is a known barrier to engagement in mental health services. We conducted an online cross-sectional study, aiming to estimate the associations between religiosity and mental illness stigma among Black adults ( n = 269, ages 18-65 years) in the United States. After adjusting for demographic factors (age, education, and ethnicity), respondents with higher attendance at religious services or greater engagement in religious activities ( e.g. , prayer, meditation, or Bible study) reported greater proximity to people living with mental health problems (rate ratio [RR], 1.72; 95% confidence interval [CI], 1.14-2.59 and RR, 1.82; 95% CI, 1.18-2.79, respectively). Despite reporting greater past or current social proximity, respondents with higher religiosity indices also reported greater future intended stigmatizing behavior (or lower future intended social proximity) (RR, 0.92-0.98). Focusing specifically on future intended stigmatizing behavior and the respondent's level of religiosity, age, and ethnicity may be critical for designing effective stigma-reducing interventions for Black adults.

Acculturation and suicide-related risk in ethnoracially minoritized youth in the US: a scoping review and content analysis of the empirical evidence.

PURPOSE: Among Asian-American/Pacific Islander, Hispanic/Latinx, and Black youth, the US born have higher risk of suicidal thoughts and behaviors (attempts and death-by-suicide) than first-generation migrants. Research has focused on the role of acculturation, defined as the sociocultural and psychological adaptations from navigating multiple cultural environments. METHODS: Using content analysis, we conducted a scoping review on acculturation-related experiences and suicide-related risk in Asian-American/Pacific Islander, Hispanic/Latinx, and Black youth (henceforth described as "ethnoracially minoritized adolescents"), identifying 27 empirical articles in 2005-2022. RESULTS: Findings were mixed: 19 articles found a positive association between acculturation and higher risk for suicide ideation and attempts, namely when assessed as acculturative stress; 3 articles a negative association; and 5 articles no association. Most of the research, however, was cross-sectional, largely focused on Hispanic/Latinx youth, relied on demographic variables or acculturation-related constructs as proxies for acculturation, used single-item assessments for suicide risk, and employed non-random sampling strategies. Although few articles discussed the role of gender, none discussed the intersections of race, sexual orientation, or other social identities on acculturation. CONCLUSION: Without a more developmental approach and systematic application of an intersectional research framework that accounts for racialized experiences, the mechanisms by which acculturation may influence the risk of suicidal thoughts and behavior remain unclear, resulting in a dearth of culturally responsive suicide-prevention strategies among migrant and ethnoracially minoritized youth.

Patient identity narratives through the cultural formulation interview in a New York City outpatient clinic.

Anthropologists have critiqued cultural competence programs in medical settings while introducing mental health clinicians to social theories on culture for practice. We explore how patients articulated narratives about themselves and how clinicians responded to such narratives through an intervention known as the Cultural Formulation Interview that anthropologists have helped develop. We conducted over 500 hours of fieldwork from 2014 to 2019 at an outpatient clinic in New York, analyzing multiple data (participant observation, medical records, patient-clinician sessions, and individual debriefing interviews) in a trial joining clinical and ethnographic methods. Our study enrolled 45 patients and six clinicians, yielding 117 patient-clinician appointments and 98 debriefing interviews. Most patients differed in how they presented their identities through demographic forms and discussed them in sessions with their clinicians. Two-thirds of the patients drew connections between their personal identities and experiences of mental illness. These results reveal why cultural identities should not be taken for granted in clinical settings.

Racial/Ethnic Disparities in Substance Use Treatment in Medicaid Managed Care in New York City: The Role of Plan and Geography.

OBJECTIVE: The aim was to assess the magnitude of health care disparities in treatment for substance use disorder (SUD) and the role of health plan membership and place of residence in observed disparities in Medicaid Managed Care (MMC) plans in New York City (NYC). DATA SOURCE: Medicaid claims and managed care plan enrollment files for 2015-2017 in NYC. RESEARCH DESIGN: We studied Medicaid enrollees with a SUD diagnosis during their first 6 months of enrollment in a managed care plan in 2015-2017. A series of linear regression models quantified service disparities across race/ethnicity for 5 outcome indicators: treatment engagement, receipt of psychosocial treatment, follow-up after withdrawal, rapid readmission, and treatment continuation. We assessed the degree to which plan membership and place of residence contributed to observed disparities. RESULTS: We found disparities in access to treatment but the magnitude of the disparities in most cases was small. Plan membership and geography of residence explained little of the observed disparities. One exception is geography of residence among Asian Americans, which appears to mediate disparities for 2 of our 5 outcome measures. CONCLUSIONS: Reallocating enrollees among MMC plans in NYC or evolving trends in group place of residence are unlikely to reduce disparities in treatment for SUD. System-wide reforms are needed to mitigate disparities.

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.

If You Don't Ask, They Don't Tell: The Cultural Formulation Interview and Patient Perceptions of the Clinical Relationship.

SYNOPSIS: More than half of participating patients expressed mistrust or ambivalence toward clinicians related to differences in cultural background using the Cultural Formulation Interview, which can help enhance communication and trust and help clinicians to anticipate treatment barriers.

Toward identifying reproducible brain signatures of obsessive-compulsive profiles: rationale and methods for a new global initiative.

BACKGROUND: Obsessive-compulsive disorder (OCD) has a lifetime prevalence of 2-3% and is a leading cause of global disability. Brain circuit abnormalities in individuals with OCD have been identified, but important knowledge gaps remain. The goal of the new global initiative described in this paper is to identify robust and reproducible brain signatures of measurable behaviors and clinical symptoms that are common in individuals with OCD. A global approach was chosen to accelerate discovery, to increase rigor and transparency, and to ensure generalizability of results. METHODS: We will study 250 medication-free adults with OCD, 100 unaffected adult siblings of individuals with OCD, and 250 healthy control subjects at five expert research sites across five countries (Brazil, India, Netherlands, South Africa, and the U.S.). All participants will receive clinical evaluation, neurocognitive assessment, and magnetic resonance imaging (MRI). The imaging will examine multiple brain circuits hypothesized to underlie OCD behaviors, focusing on morphometry (T1-weighted MRI), structural connectivity (Diffusion Tensor Imaging), and functional connectivity (resting-state fMRI). In addition to analyzing each imaging modality separately, we will also use multi-modal fusion with machine learning statistical methods in an attempt to derive imaging signatures that distinguish individuals with OCD from unaffected siblings and healthy controls (Aim #1). Then we will examine how these imaging signatures link to behavioral performance on neurocognitive tasks that probe these same circuits as well as to clinical profiles (Aim #2). Finally, we will explore how specific environmental features (childhood trauma, socioeconomic status, and religiosity) moderate these brain-behavior associations. DISCUSSION: Using harmonized methods for data collection and analysis, we will conduct the largest neurocognitive and multimodal-imaging study in medication-free subjects with OCD to date. By recruiting a large, ethno-culturally diverse sample, we will test whether there are robust biosignatures of core OCD features that transcend countries and cultures. If so, future studies can use these brain signatures to reveal trans-diagnostic disease dimensions, chart when these signatures arise during development, and identify treatments that target these circuit abnormalities directly. The long-term goal of this research is to change not only how we conceptualize OCD but also how we diagnose and treat it.

Informed consent in psychiatry outpatients.

Background & objectives: Comprehension and process of consent are important for persons with mental illness as they may not be impaired in considering research participation. The American Psychiatric Association developed a detailed Cultural Formulation Interview (CFI). The present study was a part of field testing of CFI, aimed to standardize cultural information affecting the patients' management in India. This paper describes the process and conclusions from the consent-seeking process of this study. Methods: The purpose and procedures about field trial of the CFI were introduced and the patient and caregiver were requested for participation. Consent process was carried out step by step, by reading out the consent form to the first new patient of the day in the psychiatry outpatients department of a tertiary care hospital in north India, inviting questions followed by the 'comprehension' questions. The entire process was audiotaped without any personal identifiers. The process was repeated if not comprehended. Results: A total of 67 patients consented, 11 refused and majority were educated more than secondary school. Some concerns shown by the patients and caregivers included risk of participation, loss or benefits of participation, privacy, etc. All types of mentally ill patients participated in the study. Interpretation & conclusions: Translations of consent forms used simple words, consonant with understanding of the potential participants. Patients' belief that participating in this long process would improve their care, and serve humanity, influenced their decision to participate. Except for intoxication and severe psychosis, patients could understand and comprehend issues around consent. Main issues were confidentiality and culture. Our experience in the psychiatry OPD refutes the commonly held belief that mentally ill persons lack comprehension and ability to consent.

Patient and clinician communication practices during the DSM-5 cultural formulation interview field trial.

Cultural psychiatrists and medical anthropologists have collaborated to help clinicians screen for culture-related issues in patient explanatory models of illness and to enhance the clinical processes of engagement, diagnosis, and treatment planning. This effort prioritises patient perspectives on suffering and healing to counter the trend of symptom-based interviews which assume biologically determined models of mental disorders. The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes the Cultural Formulation Interview (CFI), a semi-structured questionnaire for eliciting patient explanatory models. This paper analyses specific linguistic meanings and practices that could account for patient perceptions of improved rapport with clinicians, clinician perceptions of improving information gathering, and cultural models of health and illness during the DSM-5 field trial piloting the CFI. Twenty-seven audiotapes were analysed through the Roter Interaction Analysis System (RIAS), a standardised method for examining medical interviews based on ethnographic studies of small-group communication. After an introduction with procedural and reassurance statements to orient communication, the CFI's open-ended questions elicited patients' opinions on interpersonal, environmental, and biomedical information. Clinicians made facilitation and activation statements for patients to speak more and informed patients about what to expect. Patients constructed cultural models of illness that weaved interpersonal, environmental, and biomedical information. Clinicians and patients made rapport-building statements to each other. A RIAS-derived patient-centred score indicates that CFI sessions addressed patient concerns. Our work offers a way to analyse the discursive construction of culture in health settings and patient-centredness through detailed examinations of linguistic meanings and practices.

Examination of ataque de nervios and ataque de nervios like events in a diverse sample of adults with anxiety disorders.

BACKGROUND: Ataque de nervios (ataque) represents a cultural syndrome of paroxysmic symptoms that is described as an expression of distress among Latinx (gender-inclusive term for people of Latin-American descent). Some ataques are symptomatically similar to DSM-5-defined panic attacks, but also may include acute anger, grief, suicidal/violent behavior, or dissociation, and can last for hours or even days. Ataques usually occur after stressors and can trigger the mobilization of social support networks. Although described as a cultural syndrome, two studies showed that ataque-like events can occur in non-Latinx individuals. However, neither of the previous studies examined these events in psychiatric samples and both were hindered by methodological shortcomings. METHODS: The present study examined lifetime prevalence of ataques and ataque-like events in an ethnically/racially diverse sample of 245 adults with anxiety disorders to better understand acute reactions to stressors across cultures. RESULTS: Controlling for previously established correlates of ataque, results showed that Latinx were significantly more likely to report ever having an ataque (B = 1.41; P = 0.001; OR = 4.10 [95% CI: 1.72-9.80]), but events were reported by some non-Latinx African Americans and Whites. Anxiety sensitivity was also a significant predictor. Across the three groups, minor differences were found in symptoms, severity, or precipitants of attacks. CONCLUSIONS: Findings suggest that Latinx are more likely to experience ataques but that stressors can trigger similar symptoms in non-Latinx. However, more research is needed to understand the meaning of these attacks within non-Latinx groups as the explanations, connotations, and help-seeking expectations regarding ataque are connected to Latinx cultures.

Bridges to Better Health and Wellness: An Adapted Health Care Manager Intervention for Hispanics with Serious Mental Illness.

This study examined the feasibility, acceptability, and initial impact of bridges to better health and wellness (B2BHW), a culturally-adapted health care manager intervention for Hispanics with serious mental illness (SMI). Thirty-four Hispanics with SMI and at risk for cardiovascular disease were enrolled. Mixed-linear models were used to examine changes over 12-months on patient activation, self-efficacy, patient-rated quality of care, receipt of preventive primary care services, and quality of life. The majority of participants completed the intervention (85%) with high satisfaction. Significant improvements were found for patient activation, self-efficacy, patients' ratings of quality of care, and receipt of preventive primary care.

Feasibility, acceptability and clinical utility of the Cultural Formulation Interview: mixed-methods results from the DSM-5 international field trial.

BackgroundThere is a need for clinical tools to identify cultural issues in diagnostic assessment.AimsTo assess the feasibility, acceptability and clinical utility of the DSM-5 Cultural Formulation Interview (CFI) in routine clinical practice.MethodMixed-methods evaluation of field trial data from six countries. The CFI was administered to diagnostically diverse psychiatric out-patients during a diagnostic interview. In post-evaluation sessions, patients and clinicians completed debriefing qualitative interviews and Likert-scale questionnaires. The duration of CFI administration and the full diagnostic session were monitored.ResultsMixed-methods data from 318 patients and 75 clinicians found the CFI feasible, acceptable and useful. Clinician feasibility ratings were significantly lower than patient ratings and other clinician-assessed outcomes. After administering one CFI, however, clinician feasibility ratings improved significantly and subsequent interviews required less time.ConclusionsThe CFI was included in DSM-5 as a feasible, acceptable and useful cultural assessment tool.

Cardiovascular disease and psychiatric disorders among Latinos in the United States.

PURPOSE: Cardiovascular disease (CVD) is the leading cause of death among Latinos and disproportionately impacts people with psychiatric disorders. The aim of this study was to examine the relationships between CVD and psychiatric disorders among different Latino subgroups using a nationally representative sample. METHODS: Latinos participants (N = 6359) were drawn from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. A structured diagnostic interview was used to determine psychiatric diagnoses for any past-year mood, anxiety, and substance use disorders. A self-reported measure of physician-confirmed CVD was used. The relationships between CVD and psychiatric disorders among Latino subgroups were examined with logistic regression models adjusting for sociodemographics, CVD-risk factors, and acculturation. RESULTS: CVD were highest among Puerto Ricans (12%) and Cubans (11%), followed by Other Latinos (7%) and Mexicans (5%). The relationship between psychiatric disorders and CVD differed by Latino subgroups. Significantly increased odds of CVD were found among Mexicans with any past-year mood and anxiety disorders, Puerto Ricans with any past-year psychiatric disorders, Cubans with any past-year mood and substance abuse disorders, and Other Latinos with any past-year mood, anxiety, and lifetime schizophrenia/psychotic disorders. CONCLUSIONS: The associations between CVD and psychiatric disorders are not uniform among Latinos. Efforts to address the need for health and mental health services must carefully consider this heterogeneity.

Developing Research Collaborations in an Academic Clinical Setting: Challenges and Lessons Learned.

Research collaboration in "real world" practice settings may enhance the meaningfulness of the findings and reduce barriers to implementation of novel intervention strategies. This study describes an initiative to integrate research into a hospital-based outpatient psychiatric clinic within an academic medical center, focusing on collaborative processes across three research projects. We report on the varied outcomes of the projects and utilize data from two focus groups to identify the key elements that contributed to the challenges and successes. We identify barriers to practice-research collaborations that emerged even when the initial circumstances of the partnership were favorable. These barriers include the presence of varied agendas across clinicians and investigators, resource constraints, limited staff buy-in, and staff turnover. In highlighting the lessons learned in this collaborative process, we hope to facilitate successful partnerships in other clinical settings.

The role of clinical experience, diagnosis, and theoretical orientation in the treatment of posttraumatic and dissociative disorders: A vignette and survey investigation.

Controversy exists regarding the merits of exposure-based treatments for posttraumatic stress disorder (PTSD) versus a phased approach when prominent dissociative symptoms are present. The first aim of this study was to examine the degree to which diagnosing dissociation in two traumatized patients' vignettes influenced clinicians' preference for phase-oriented treatment and whether clinicians' treatment experience contributed to their treatment preference. The second aim was to assess the extent to which participants had observed traumatized patients worsen when treated with exposure therapy or phase-oriented therapy and whether the theoretical orientation and treatment experience of the clinician were related to the observed deterioration. In the tradition of expert and practitioner surveys, 263 clinicians completed a survey of their diagnoses and treatment preferences for two vignettes and their treatment experience, theoretical orientation, and observations of patients' deterioration. When a marked degree of dissociation was noted in the PTSD vignette, respondents favored phased approaches regardless of the diagnosis given. Reports of having observed patient deterioration during both exposure and phased therapy were predicted by years of experience. Psychodynamic therapists reported more observations of worsening during exposure therapy than cognitive behavior therapy therapists. Clinical experience treating PTSD may heighten awareness of negative therapeutic effects, potentially because experienced clinicians have a lower threshold for detecting such effects and because they are referred more challenging cases.

Life Is Precious: Views of Adolescents and Their Mothers on Methods to Reduce Suicidal Behavior in Latinas.

Life is Precious (LIP) was developed to help reduce suicidal behavior in Latina adolescents. As part of an external evaluation of the LIP program, we conducted focus groups with adolescent participants and mothers to learn whether participants and families believe that the activities of LIP address risks for suicidal behavior. Four focus groups were conducted: three with Latina adolescent LIP participants ( n = 31) and one with mothers ( n = 8). Transcripts were analyzed using ATLAS.ti. A grounded theory approach was used to identify themes and subthemes. The following themes emerged: (1) challenges contributing to suicidal behavior and self-harm among Latina adolescents, (2) how respondents believe that LIP is helping to reduce suicidal behavior, and 3) ongoing challenges. Participants say that the LIP program helps adolescents feel better and improve social relationships, academic performance, and relationships with their family. School nurses may wish to identify community-based programs offering similar services.

Rethinking funding priorities in mental health research.

Mental health research funding priorities in high-income countries must balance longer-term investment in identifying neurobiological mechanisms of disease with shorter-term funding of novel prevention and treatment strategies to alleviate the current burden of mental illness. Prioritising one area of science over others risks reduced returns on the entire scientific portfolio.