Developing culturally sensitive psychiatric diagnostic assessments : clinical evaluation of the DSM-5 Cultural Formulation Interview

Background: Culture and social context influence how symptoms of distress are expressed and interpreted, posing challenges in transcultural psychiatric assessments. This increases the risk that mental disorders among migrants and ethnic minorities are diagnosed late, misdiagnosed, or undetected.

The Cultural Formulation Interview (CFI) in the DSM-5 is a person-centered tool developed to facilitate the exploration of cultural and contextual factors of mental distress in a non-stereotypic and individualized way.

Aims: The overall aim of this research project was to evaluate the culture-sensitive and person-centered tool, the Cultural Formulation Interview (CFI), included in the psychiatric diagnostic manual DSM-5. Study I aimed to investigate whether adding the DSM-5 core CFI to routine diagnostic procedures impacts the diagnostic outcome. Study II aimed to assess the Clinical Utility (CU), Feasibility (F) and Acceptability (A) of the CFI for clinicians and patients, and to explore clinicians' experiences of using the CFI in a multicultural clinical setting. Study III aimed to find out the gain of information deriving from the use of the CFI questions with non-native Swedish speaking patients, and to understand how they may facilitate identification of psychiatric diagnoses among these patients. Study IV aimed to find out the gain of information deriving from the use of the CFI questions with native Swedish-speaking patients, and to understand what kind of information the questions about background and identity yielded when used with these patients.

Materials and methods: In Study I, we conducted a randomized controlled trial comparing the outcome of a diagnostic procedure that included the CFI (intervention) with routine diagnostic procedures (control) at Swedish psychiatric clinics. New patients (n=256) admitted to a psychiatric outpatient clinics were randomized to control (n=122) or CFI-enhanced diagnostic procedure (n=134). An intention-to-treat analysis was performed, calculating the prevalence ratios and corresponding 95% confidence intervals (CI) for diagnoses of depressive and anxiety disorders, multiple diagnoses, and delayed diagnoses.

In Study II, a mixed method design was applied, using a Debriefing Instrument for Clinicians (DIC) (N=15) and a Debriefing Instrument for Patients (DIP) (N=114) (DIC and DIP, scored from -2 to 2). Focus group interviews were conducted with clinicians using the CFI.

In Study III, qualitative thematic analysis was used to analyze the 47 documented CFI answers from non-native Swedish speaking patients and in Study IV the same method was used on the 62 documented CFI answers from native Swedish speaking patients.

Results: Results from Study I showed a prevalence ratio (PR) of a diagnosis of depressive disorder of 1.21 (95% CI=0.83-1.75). The prevalence ratio was higher among patients whose native language was not Swedish (PR =1.61, 95% CI=0.91-2.86). In the CFI group, the prevalence ratio for receiving multiple diagnoses was higher among non-native speakers and lower among native Swedish speakers (PR =. 39, 95% CI=0.18-0.82).

In Study II, both patients and clinicians found the CFI to be acceptable (A), feasible (F) and clinically useful (CU). The results from the DIP showed a CU mean 0.98 (SD 0.93), on a scale between -2 and +2, and a F mean 1.07 (SD 0.83). The overall rating of the interview was 8.30 (SD 1.75) on a scale between 0 and 10. For DIC (response rate 94%), the CU mean was 1.14 (SD 0.52), F mean 0.58 (SD 0.93) and A mean 1.42 (SD 0.44). The focus-group interviews indicated that using the CFI at the initial contact can facilitate the patient's illness narrative.

The thematic analysis of CFI answers in Study III and IV yielded information about how the patients described, managed, and made sense of their distress. In Study III, the non-native Swedish speakers often described their distress in relation to functionality in everyday life and used a combination of somatic and emotional expressions. These patients often related their identity to a sense of belonging to their culture of origin. In Study IV, the native Swedish speaking patients often described and explained their symptoms in psychiatric terms. They often used emotional expressions and related their identity to the ability to perform in relation to a social role.

Conclusions: The results suggest that

• the CFI in the DSM-5 seems to be a feasible, acceptable, and clinically useful assessment tool

• the contextualized information gained through the CFI can assist clinicians in identifying psychiatric symptoms when language, psychiatric terminology, and explanations are not shared between the patient and clinician

• implementing the DSM-5 CFI in routine psychiatric diagnostic practice can facilitate identification of symptoms of certain psychiatric disorders

• there is a need of re-framing the questions about cultural identity and its impact on health

List of scientific papers

I. Wallin, M. I., Galanti, M. R., Nevonen, L., Lewis-Fernández, R., & Bäärnhielm, S. (2022). Impact on routine psychiatric diagnostic practice from implementing the DSM-5 cultural formulation interview: a pragmatic RCT in Sweden. BMC psychiatry. 22(1), 149.
https://doi.org/10.1186/s12888-022-03791-9

II. Wallin, M. I., Dahlin, M., Nevonen, L., & Baarnhielm, S. (2020). Patients' and clinicians' experiences of the DSM-5 Cultural Formulation Interview: A mixed method study in a Swedish outpatient setting. Transcultural psychiatry. 57(4), 542-555.
https://doi.org/10.1177/1363461520938917

III. Wallin, M. I., DeMarinis, V., Nevonen, L., & Bäärnhielm, S. (2024). A qualitative analysis of the documentation of DSM-5 Cultural Formulation Interviews with non-native speaking patients in a Swedish mental health care setting. Frontiers in psychiatry. 15, 1298920.
https://doi.org/10.3389/fpsyt.2024.1298920

IV. Wallin, M. I., DeMarinis, V., Nevonen, L., & Baarnhielm, S. (2024). What information did the DSM-5 Cultural Formulation Interviews provide when used with Swedish-speaking patients in a psychiatric setting in Stockholm? Frontiers in psychiatry. 15, 1377006.
https://doi.org/10.3389/fpsyt.2024.1377006