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Comment & Response
March 24/31, 2020

Cultural Influences in Psychiatry

Author Affiliations
  • 1New York State Psychiatric Institute, Columbia University, New York
JAMA. 2020;323(12):1192. doi:10.1001/jama.2020.1086

To the Editor Dr Guinart and colleagues1 asked if transcultural psychiatry is possible. The answer for clinicians in cultural psychiatry is “yes.” However, I have some comments about the article.

The authors wrote: “There is still little research about how culture affects the evaluation of symptoms and signs that are relevant for psychiatric diagnosis and treatment.”1 However, diagnosis of psychiatric disorders is an act of double interpretation: without laboratory or radiological biomarkers, clinicians interpret a patient’s narrative as a biomedical diagnosis, and the patient’s narrative is a linguistic interpretation of subjective distress.2 After the Diagnostic and Statistical Manual of Mental Disorders (Third Edition; DSM-III), even with standardized criteria for each disorder, North American and European psychiatrists have consistently diagnosed patients from minority groups as having more severe illnesses than patients from majority groups with similar presentations, raising questions about how biases affect interpretations.3

The authors also wrote that the DSM-5 “moved away from listing idiosyncratic, region-specific syndromes and introduced the idea of cultural concepts of distress. Doing so, the authors of the DSM-5 underlined the universality of distress that may be expressed differently but still relates to the same underlying biology of anxiety, depression, or acute stress reaction.”1 However, the DSM-5 says: “The current formulation acknowledges that all forms of distress are locally shaped, including the DSM disorders.”4 Studies are needed outside of North America and Western Europe that compare how symptom presentations correspond with DSM criteria. Otherwise, the assumption is that DSM criteria are universal, excluding presentations that do not fit these criteria. But such excluded presentations may reflect the interaction of culture and biology. Symptom presentations common across groups may reflect a universal biology whereas symptom variations may reflect cultural differences from population variance.3

Although all clinicians could benefit from training in the Cultural Formulation Interview (CFI) to improve cultural competence, the CFI has also faced translation challenges. In a 6-country field trial that tested the feasibility, acceptability, and clinical utility of the CFI with 318 patients and 75 clinicians, words such as culture and identity were not conceptually equivalent across languages.5 Historical constructions of social differences informed how patients answered the questions on culture and identity: in the United States, discussions centered on race and ethnicity; in India, on caste and religion; in Kenya, on tribe; in Peru, on mestizaje.5

It may take time to integrate findings from transcultural psychiatry with neuroscience. But Guinart and colleagues correctly argued that the concerns of transcultural psychiatry are relevant across medical specialties.

Section Editor: Jody W. Zylke, MD, Deputy Editor.
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Article Information

Corresponding Author: Neil Krishan Aggarwal, MD, MA, New York State Psychiatric Institute, 1051 Riverside Dr, Unit 11, New York, NY 10032 (neil.aggarwal@nyspi.columbia.edu).

Conflict of Interest Disclosures: Dr Aggarwal reported being an advisor to the DSM-5 Cross-Cultural Issues Subgroup and a member of the DSM-5-TR Culture Review Committee.

References
1.
Guinart  D, Kane  JM, Correll  CU.  Is transcultural psychiatry possible?  JAMA. 2019;322(22):2167-2168. doi:10.1001/jama.2019.17331PubMedGoogle ScholarCrossref
2.
Kleinman  A.  Rethinking Psychiatry: From Cultural Category to Personal Experience. Free Press; 1988.
3.
Aggarwal  NK.  Culture, communication, and DSM-5 diagnostic reliability.  J Natl Med Assoc. 2017;109(3):150-152. doi:10.1016/j.jnma.2017.03.005PubMedGoogle ScholarCrossref
4.
American Psychiatric Association. Cultural formulation: cultural concepts of distress. In:  Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013:758.
5.
Lewis-Fernández  R, Aggarwal  NK, Hinton  L, Hinton  DE, Kirmayer  LJ.  DSM-5 Handbook on the Cultural Formulation Interview. American Psychiatric Publishing; 2016.
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