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Comment & Response
March 24/31, 2020

Cultural Influences in Psychiatry

Author Affiliations
  • 1Dr Paralikar’s Clinic, Pune, India
  • 2Psychiatry Unit, KEM Hospital, Pune, India
JAMA. 2020;323(12):1192-1193. doi:10.1001/jama.2020.1091

To the Editor In a Viewpoint, Dr Guinart et al1 highlighted the need for fuller consideration of transcultural psychiatry to better explain cultural variation in clinical trials of psychotropic medicines. As the article suggested, such research is bedeviled by questions of interrater reliability, variations in the expression of stigmatizing emotional experience, and capacity for measuring treatment response. Neglecting cultural contexts distorts the results of clinical trials. Such concerns about cultural validity for effective clinical practice, in fact, motivated formulation of the “new cross-cultural psychiatry” as an upgrade for transcultural psychiatry more than 4 decades ago.2

The DSM-5 places renewed emphasis on culture with inclusion of an updated Outline for Cultural Formulation from the DSM-IV and development of a new clinical assessment tool, the CFI. Notwithstanding the demonstrated value of these resources for cultural assessment in clinical practice globally,3 experience using these tools indicates a need for further refinement, which is warranted for clinical practice and essential for the level of culturally sophisticated transcultural research advocated by Guinart et al.1

Analysis of CFI data at a field site of the CFI validation studies for the DSM-5 indicated how rethinking the Outline for Cultural Formulation provides a way forward.4 Two domains of the outline concerned with cultural identity and illness explanatory models remain highly relevant core features of cultural formulation. Two other domains, however, considering psychosocial environment and patient-clinician relationships, were found to be imprecise and inadequate in accounting for the social and cultural significance of interpersonal relationships and important political-economic structural features of society and health systems that are major factors affecting patients’ problems and helpful interventions. The role of structural factors is illustrated by case studies in social medicine, including some dealing explicitly with psychiatric problems.5 Social and structural domains need to be included as core features of a revised Outline for Cultural Formulation. Such refinement is needed not only to better meet clinical challenges addressed in the DSM-5 but also to acknowledge the relevance of transcultural psychiatry in research, and to show how the answer to the rhetorical question about the possibility of transcultural psychiatry for research, posed by Guinart and colleagues,1 should be yes.

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

Corresponding Author: Ankita Deshmukh, MPhil, Dr Paralikar’s Clinic, 101 SOBA Mansion, Erandwane, Pune 411004, India (ankita.deshmukh.work@gmail.com).

Conflict of Interest Disclosures: None reported.

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  AM.  Depression, somatization and the “new cross-cultural psychiatry.”  Soc Sci Med. 1977;11(1):3-10. doi:10.1016/0037-7856(77)90138-XPubMedGoogle ScholarCrossref
3.
Lewis-Fernández  R, Aggarwal  NK, Lam  PC,  et al.  Feasibility, acceptability and clinical utility of the Cultural Formulation Interview: mixed-methods results from the DSM-5 international field trial.  Br J Psychiatry. 2017;210(4):290-297. doi:10.1192/bjp.bp.116.193862PubMedGoogle ScholarCrossref
4.
Paralikar  VP, Deshmukh  A, Weiss  MG.  Qualitative analysis of Cultural Formulation Interview: findings and implications for revising the Outline for Cultural Formulation.  Transcult Psychiatry. 2019; doi:10.1177/1363461518822407PubMedGoogle Scholar
5.
Kalofonos  I.  Biological citizenship—a 53-year-old man with schizoaffective disorder and PTSD applying for Supplemental Security Income.  N Engl J Med. 2019;381(21):1985-1989. doi:10.1056/NEJMp1811661PubMedGoogle ScholarCrossref
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