
- Vol 39, Issue 11
The Cross-Cultural Dimensions of Psychosis
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.
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 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
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
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
2. Diagnosis of a psychotic disorder. Psychiatrists are more likely to diagnose BIPOC individuals with a
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
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
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
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
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.
References
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.
3. Aggarwal NK, Like R, Kopelowicz A, et al.
4. Bhui K, Warfa N, Edonya P, et al.
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.
9. Schoer N, Huang CW, Anderson KK.
10. Misra S, Etkins OS, Yang LH, Williams DR.
11. Halvorsrud K, Nazroo J, Otis M, et al.
12. Linscott RJ, van Os J.
13. Lawson W, Johnston S, Karson C, et al.
14. Williams JC, Harowitz J, Glover J, et al.
15. Tadmon D, Olfson M.
16. Levin JB, Seifi N, Cassidy KA, et al.
17. Phillips KL, Copeland LA, Zeber JE, et al.
18. Adeponle AB, Thombs BD, Groleau D, et al.
19. Aggarwal NK, Lam P, Diaz S, et al.
20. Muralidharan A, Schaffner RM, Hack S, et al.
Articles in this issue
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Covering the Basics: LGBTQ+ Terminologyalmost 3 years ago
The Importance of Avoiding Implicit Bias in Advocating for Patientsalmost 3 years ago
Psychiatrist Humility and Patient Empowermentalmost 3 years ago
Advances and Challenges in Adult ADHDalmost 3 years ago
THE QUEST: Nepal Lets You Reach for the Majesty of the Summitalmost 3 years ago
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