The Cross-Cultural Dimensions of Psychosis

Psychiatric TimesVol 39, Issue 11

All medical students, psychiatry residents, fellows, faculty at academic medical institutions, and psychiatrists in independent practice must develop skills in cultural competence to avoid perpetuating disparities in health outcomes for BIPOC individuals with serious mental illnesses.


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Psychiatrists have been interested in the cross-cultural dimensions of psychosis since Emil Kraepelin (1856-1926) sailed to Java in 1904 and published his pivotal Vergleichende Psychiatrie(Comparative Psychiatry). Kraepelin provided the first known comparison of psychotic symptoms across populations: “The early stages of a depression were rarely seen, and violent excitement was also uncommon, but at the same time the very severe forms of dementia, so common in our own mental hospitals and found among the Europeans in Java as well, seem rarely to develop among the indigenous population.”1

Today’s psychiatrists in North America and Europe do not need to go abroad to encounter individuals of different races and ethnicities. Affordable travel and developments in information technology have led to large-scale population migrations so that more physicians and patients identify as Black, Indigenous, and people of color (BIPOC).2 Due to the increased likelihood of cross-cultural patient-clinician interactions, all medical students, psychiatry residents, fellows, faculty at academic medical institutions, and psychiatrists in independent practice in certain American states must develop skills in cultural competence3 to avoid perpetuating disparities in health outcomes for BIPOC individuals with serious mental illnesses.4 This raises a fundamental question of how to understand terms like culture and cultural competence. DSM-5-TR defines culture as follows5:

“Culture refers to systems of knowledge, concepts, values, norms, and practices that are learned and transmitted across generations. Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, customs, and ways of understanding health and illness, as well as moral, political, economic, and legal systems. Cultures are open, dynamic systems that undergo continuous change over time; in the contemporary world, most individuals and groups are exposed to multiple cultural contexts, which they use to fashion their own identities and make sense of experience.”

The Centers for Medicare & Medicaid Services—the largest funder of mental health services in the United States—defines cultural competence as “the capacity to identify, respect, and understand differences in cultural beliefs, behaviors, and needs of consumers.”6 Decades before cultural competence became mandatory for clinicians, cultural psychiatrists pointed out that psychiatrists have their own professional cultures with biomedical knowledge, concepts, values, norms, and practices that introduce barriers to care.7 This article synthesizes research on how culture can impact psychosis across the mental health services pathway. It offers suggestions for providing culturally competent care and ways of overcoming potential challenges.

Cultural Considerations

The health services pathway can be divided into 4 discrete phases: help-seeking through first contact with a mental health clinician, receiving the diagnosis of a psychotic disorder, initiating treatment such as psychotherapy or pharmacotherapy, and adhering to treatment.8 Cultural differences among patients and clinicians affect each step.

1. Help-seeking. Compared with those who are from majority ethno-racial populations in high-income North American and European countries, BIPOC individuals may make sense of their initial psychotic symptoms through shame and stigma,9 and are more likely to distrust psychiatrists based on experiences of racism, which delays their initial contact with mental health clinicians.10

Case 1: “Mrs Williams” is a Black American woman who contacts her son’s pediatrician about concerns related to behavioral changes. Her son’s teachers report that he stopped participating in classes. She thought his behaviors were part of normal adolescent development, but when he started to say that the US government wants to kill all Black individuals, she became concerned. Her pediatrician makes a referral to a child and adolescent psychiatrist who asks how long her son had been experiencing paranoid delusions. She says “about 9 months.” He asks why she did not seek care sooner. She informs him that with so many instances in the news of Black males with mental illnesses experiencing violence from law enforcement officials, she did not want her son to be labeled. He evaluates her son, counsels her about first-episode psychosis, and gains her trust by guiding her through the special educational services process with the US Department of Education for her son to receive medical accommodations.

2. Diagnosis of a psychotic disorder. Psychiatrists are more likely to diagnose BIPOC individuals with a psychotic disorder rather than a mood disorder based on misinterpreting symptoms.11 Studies across countries show that individuals from minoritized ethno-racial backgrounds have 1.35 higher odds compared with majority populations of reporting hallucinations or delusions that are clinically subthreshold and do not meet full criteria for a psychotic disorder, perhaps due to greater acculturative stresses.12 Psychiatrists unfamiliar with the cultural backgrounds of patients or who exhibit biases are more likely to exacerbate misdiagnoses.

Case 2: “Mr Delgado” is an agricultural worker in his 40s who comes to the United States on a seasonal H-2 visa every year to harvest oranges. His mother died 5 months ago. He presents for an initial evaluation at an outpatient clinic run by residents and fellows. Although he is sad and tearful, he describes himself as interacting more with colleagues at work and better able to focus than he was right after his mother died. “Dr Xi,” a Chinese American physician, asks whether he can hear or see things others cannot. Mr Delgado replies that he sometimes hears his mother’s voice and sees her image in the form of a guardian angel. Because of his interests in cross-cultural care, Dr Xi asks whether these experiences are common in Mr Delgado’s community. Mr Delgado says yes. Dr Xi asks whether if Mr Delgado wants to try a medication to help treat the visions or only to treat his poor mood, anhedonia, and low motivation. Mr Delgado says he finds the visions comforting. Both agree to initial treatment with an antidepressant. Mr Delgado comes back 3 months later, before he is to return to Mexico, and thanks Dr Xi for acknowledging his treatment preferences. He no longer describes extrasensory hallucinations.

3. Initiating treatments. Psychiatrists are less likely to offer BIPOC individuals with psychosis a second-generation oral antipsychotic and more likely to offer long-acting injectable agents.13 BIPOC individuals are also less likely to receive clozapine14 and psychotherapy as treatment options.15

4. Treatment adherence. Although patients from all ethno-racial groups exhibit negative attitudes toward pharmacotherapy to treat psychotic disorders, BIPOC individuals are more likely to discontinue these medications due to concerns about adverse effects.16 Due to implicit biases, psychiatrists are less likely to monitor metabolic parameters for BIPOC patients with psychotic disorders who take antipsychotics.17 Fortunately, clinical research is increasingly showing how psychiatrists can develop cultural competence skills to improve patient care.

The Cultural Formulation Approach

Studies show that the cultural formulation approach can elicit the knowledge, concepts, values, norms, and practices that individuals with psychosis employ to make sense of their experiences. Researchers with McGill University’s Cultural Consultation Service have used an expanded version of the DSM-IV-TR Outline for Cultural Formulation to assess for cultural issues related to diagnosis, treatment planning, and treatment adherence. Clinicians collaborating with cultural and linguistic brokers and presenting cases in a multidisciplinary conference were able to rediagnose 34 of 70 cases (49%) from a referral diagnosis of a psychotic disorder to a nonpsychotic disorder, and rediagnose 12 of 253 (5%) cases from a referral diagnosis of a nonpsychotic disorder to a psychotic disorder.18 Although changes in diagnoses occurred across all ethno-racial groups, immigrants and refugees were misdiagnosed more with an initial psychotic disorder, showing that cultural information related to how individuals make sense of their experiences can affect diagnostic assessment and treatment selection.18

Many psychiatrists may not have access to a cultural consultation service or may find that cultural issues exist even with patients who share their ethnic, racial, and religious backgrounds. DSM-5 and DSM-5-TR include a series of semistructured interviews known collectively as the Cultural Formulation Interview (CFI), which the American Psychiatric Association has disseminated free of cost. The 16-question version for use with patients can be found at A 17-item for use with informants can be found at

Clinical studies show mixed results in individuals with psychosis. The interview can require more reflection on personal identity and treatment planning than can be tolerated by patients with florid hallucinations or paranoid delusions.19 However, stable outpatients with chronic illnesses felt that clinicians using the CFI validated their experiences and presented new avenues for recovery.20 Practicing clinicians may find the CFI helpful upon resolution of acute symptoms. Cultural competence is a lifelong pursuit; tools like the CFI can help clinicians take that first step.

Dr Aggarwal is an assistant professor of clinical psychiatry at Columbia University, and a research psychiatrist at New York State Psychiatric Institute in New York, New York.


1. Kraepelin E. Vergleichende Psychiatrie. Centralblatt für Nervenheilkunde und Psychiatrie. 1904;27(Neue Folge Bd.15):433-437; reprinted and translated by E Wittkower: Comparative psychiatry. Transcult Psychiatric Res Rev. 1974;11:108-112.

2. Bibeau G. Cultural psychiatry in a creolizing world: questions for a new research agenda. Transcult Psychiatry. 1997;34(1):9-41.

3. Aggarwal NK, Like R, Kopelowicz A, et al. Has the time come for a cultural psychiatry fellowship in the USA? Acad Psychiatry. 2016;40(6):928-931.

4. Bhui K, Warfa N, Edonya P, et al. Cultural competence in mental health care: a review of model evaluations. BMC Health Serv Res. 2007;7:15.

5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. American Psychiatric Association; 2022. Accessed June 24, 2022.

6. Cultural competence and language assistance. Centers for Medicare & Medicaid Services. Accessed June 24, 2022.

7. Kleinman A. Patients and Healers in the Context of Culture: An Exploration of the Borderland between Anthropology, Medicine, and Psychiatry. University of California Press; 1980.

8. Singh SP, Grange T. Measuring pathways to care in first-episode psychosis: a systematic review. Schizophr Res. 2006;81(1):75-82.

9. Schoer N, Huang CW, Anderson KK. Differences in duration of untreated psychosis for racial and ethnic minority groups with first-episode psychosis: an updated systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2019;54(10):1295-1298.

10. Misra S, Etkins OS, Yang LH, Williams DR. Structural racism and inequities in incidence, course of illness, and treatment of psychotic disorders among Black Americans. Am J Public Health. 2022;112(4):624-632.

11. Halvorsrud K, Nazroo J, Otis M, et al. Ethnic inequalities in the incidence of diagnosis of severe mental illness in England: a systematic review and new meta-analyses for non-affective and affective psychoses. Soc Psychiatry Psychiatr Epidemiol. 2019;54(11):1311-1323.

12. Linscott RJ, van Os J. An updated and conservative systematic review and meta-analysis of epidemiological evidence on psychotic experiences in children and adults: on the pathway from proneness to persistence to dimensional expression across mental disorders. Psychol Med. 2013;43(6):1133-1149.

13. Lawson W, Johnston S, Karson C, et al. Racial differences in antipsychotic use: claims database analysis of Medicaid-insured patients with schizophrenia. Ann Clin Psychiatry. 2015;27(4):242-252.

14. Williams JC, Harowitz J, Glover J, et al. Systematic review of racial disparities in clozapine prescribing. Schizophr Res. 2020;224:11-18.

15. Tadmon D, Olfson M. Trends in outpatient psychotherapy provision by U.S. psychiatrists: 1996-2016. Am J Psychiatry. 2022;179(2):110-121.

16. Levin JB, Seifi N, Cassidy KA, et al. Comparing medication attitudes and reasons for medication nonadherence among three disparate groups of individuals with serious mental illness. J Nerv Ment Dis. 2014;202(11):769-773.

17. Phillips KL, Copeland LA, Zeber JE, et al. Racial/ethnic disparities in monitoring metabolic parameters for patients with schizophrenia receiving antipsychotic medications. Am J Geriatr Psychiatry. 2015;23(6):596-606.

18. Adeponle AB, Thombs BD, Groleau D, et al. Using the cultural formulation to resolve uncertainty in diagnoses of psychosis among ethnoculturally diverse patients. Psychiatr Serv. 2012;63(2):147-153.

19. Aggarwal NK, Lam P, Diaz S, et al. Clinician perceptions of implementing the Cultural Formulation Interview on a mixed forensic unit. J Am Acad Psychiatry Law. 2020;48(2):216-225.

20. Muralidharan A, Schaffner RM, Hack S, et al. “I got to voice what’s in my heart”: participation in the Cultural Formulation Interview—perspectives of consumers with psychotic disorders. J Psychosoc Rehabil Ment Health. 2017;4(1):35-43.

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