Current Controversies in Diagnostic Accuracy of DSM Disorders in Minority Groups

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Current Controversies in Diagnostic Accuracy of
DSM Disorders inMinority Groups

• 37th Semi-annual Substance Abuse Research
  Consortium (SARC)
• May 30, 2008
• William A. Vega
• Professor
• David Geffen School of Medicine
• UCLA

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Aims of presentation

• To briefly review the conceptual and
  methodological issues bearing on the reliability
  and validity of research and clinical diagnoses
  of drug disorders
• To examine diagnostic inconsistencies between
  U.S. ethnic and demographic subgroups
• To briefly review emerging evidence of language
  and cultural effects on symptoms and diagnoses
• Make recommendations to improve diagnoses and
  clinical treatment

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• Culture
• A shared set of beliefs, norms, or values that
  will influence the meaning given to life events
  and experiences

Schraufnagel TJ. Gen Hosp Psychiatry.
200628(1)27.
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Culture and mental health

• Culture defines the meaning and acceptability of
  drug use behavior
• Behavior is controlled by behavior norms
• Families are the primary social institution for
  emotional support and establishing behavior
  expectations in children
• Society also influences behavior by providing
  opportunities for human development and linking
  families and individuals to social institutions
  but the level of influence varies widely
• Large sectors of the minority populations are
  socially isolated
• Drug use patterns highly idiosyncratic by ethnic
  groups in U.S. and across different societies

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Aspects of Cultural Identity
Adapted from Ton H, Lim RF. The assessment of
culturally diverse individuals. In Lim RF
(ed). Clinical Manual of Psychiatry. Arlington,
VA American Psychiatric Publishing 200610.
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Tensions in the DSM approach

• The DSM is a descriptive manual of disorders and
  is atheoretical and complex with symptom overlap
• The DSM is supposed to be a framework for
  research
• The disorders are determined by committee action
  and have expanded exponentially over the past 30
  years from a handful to hundreds
• Etiologic information is supposed to inform the
  formation of the categories but we have no
  biologic markers of disorders available and no
  confirmed causal models
• Language is the primary bases for establishing a
  diagnosis reliance on effective communication

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The question is whether different genotypes
have a different relationship to the phenotype in
different environments.

• Cooper, R.S. (2003) Gene-environments
  interactions and the etiology of common complex
  disease. Ann Inter Med 139437-440

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Context Dependence Gene-Environment Interaction
Model
GVP
Phenotype
GVP
GVA
GVA
Mexico
USA
Exposure
Adapted from Cooper, R.S. (2003). Annals of
Internal Medicine, 139437-440
GVA Gene Variant Absent GVP Gene Variant
Present
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Lifetime DSM-IV Rates () of Substance Disorders
in Mexican Women and Mexican-origin Women in
U.S.

• 1 NESARC. 2 from M. Medina-Mora et al., in
  press.

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Lifetime DSM-IV Rates () of Substance Disorders
in Mexican Men and Mexican-origin Men in U.S.

• 1 NESARC. 2 from M. Medina-Mora et al., in
  press.

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SUD and Ethnicity

• U.S. has the highest 12-month prevalence of
  substance (DSM-IV) disorders (3.8) in the WHO MH
  Surveys across 14 countries (excepting Ukraine),
  and 13.5 times higher then Spain!
• Drug dependence is not more pervasive in U.S.
  ethnic groups than in Whites
• Reactivity to cumulative adversity is lower among
  ethnic minorities- better coping or displacement
  to other medical disorders?

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Methods issues

• Are substance disorders best measured as
  categorical or dimensional phenomena, or a
  combination of the two?
• What statistical procedure can best accomplish
  this?
• What are the implications for clinical diagnoses
• Will resolution differ by drug phenotype
• type?
• Are drug disorder phenotypes influenced by
  culture?

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Sources of bias in the diagnostic process low
concordance and misdiagnoses

• Patient ethnicity
• Patient language use
• Clinician ethnicity
• Clinician language use
• Clinician training
• Clinician awareness of stereotyping effects on
  diagnostic process
• Etic vs. emic criteria semantic relevance and
  common meaning

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Cross-cultural reliability of diagnostic criteria

• What do we know about the phenomenology of
  diagnoses for drug dependence?
• How might it be influenced by ethnicity,
  nativity, language use, sex, and SES?
• Is their sufficient information to establish the
  validity of substance abuse and dependence
  criteria?
• How does the life course of SUD onset,
  persistence, and remission differ by ethnicity?
• How do dual diagnoses, subsyndromal, and orphan
  disorder patterns differ by ethnicity and ethnic
  subgroup factors?

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Culturally laden terms

• Evaluating meaning of loss of control and
  craving
• Can you preserve the equivalence of these
  diagnostic terms cross- culturally?
• Risk taking and impulsivity have been shown to
  vary greatly by nativity among Latinos

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Dual diagnoses

• Are current criteria optimal diagnoses of dual
  diagnoses?
• Does dual diagnoses require all criteria for a
  SUD to be clinically meaningful and treatable?
• What about binge vs continuous substance use,
  which may be culturally influenced even within
  ethnic groups?
• Should full criteria be met for a non addictive
  disorder to establish the presence of a substance
  induced condition?
• How do phenomenological dual diagnoses patterns
  vary by ethnicity?

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NLAAS dual diagnoses rates for U.S. national
sample of Latinos

• Any alcohol abuse/dependence with or without drug
  dependence, and a co-occurring non-addictive
  DSM-IV disorder
• Total for immigrant women 0.68,men 5.25
• Total for U.S. born women 7.33, men 16.22

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Confounds in the diagnostic process Ethnicity
and psychoses

• Putative psychotic symptoms are commonly reported
  by Latinos who are medical patients, psychiatric
  patients, or non-symptomatic
• Incongruent psychotic features are frequently
  reported by depressed Latino patients
• Negligible research available about expressions
  of psychotic depression in ethnic groups

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Population studies of African Americans

• Reported from a registry study of a cohort born a
  Oakland childrens hospital disproportionately
  high rates of schizophrenia among African
  Americans compared to whites two decades later
  based on treatment records Bresnhan et al., Int.
  J. Epi., 2007
• ECA studies failed to find major differences in
  rates by ethnic group for depression or
  schizophrenia, and WHO estimated 1 rate in
  review of international sites
• Limitation psychotic disorders notoriously
  difficult to diagnose in clinical (usual care)
  and community studies due to poor inter-rater
  reliability, hiatus on field ascertainment
• Ethnicity and language of both patients and
  clinicians are confounders in diagnostic studies

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Knowing your patientWilliam Lawson, M.D.

• Patient disclosure
• Patient engagement
• Cultural nuances in presentation
• Social factors

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Accurate diagnosis Steven Strakowski, M.D.

• Common trouble spots in diagnosing African
  American patients for schizophrenia error rate
  44 vs. 18 for whites
• Clinician tendencies regarding first rank
  symptoms in the diagnostic process
• Overvaluing substance use, hallucinations and
  delusions and undervaluing or not fully assessing
  mood symptoms

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Improving care for African American patients

• Goals
• Overcoming documented problems in diagnosis and
  medication
• Improving patient evaluation
• Improving effective communication
• Improving compliance

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Recommendations of recent expert reviews

• Improve and disseminate knowledge about
  culturally competent care
• Rapid information transfer to practitioners
• Identify and address documented disparities in
  quality of care
• Increase accountability through monitoring
  outcomes of care

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Be aware of personal bias and countertransference
, and keep in mind that a patient is first and
foremost an individual. Do not let
cultural-specific information obscure the
individual patient, which can occur if the
healthcare provider treats the information
stereotypically and acts as if all members of an
ethnic category must behave and believe in the
same fashion. A. Hardwood
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Vega et al. Nerv. Ment. Dis. 2006

• Putative psychotic symptoms commonly reported in
  community sample of Mexican origin people in
  California
• Rates highest among U.S. born lower among
  immigrants
• Psychotic symptoms increased if psychiatric
  disorders are comorbid and are highest if
  multiple disorders reported
• Prevalence of mood disorders was 15 in U.S. born
  women with no psychotic symptoms, and 38 if
  reporting psychotic symptoms
• First rank symptoms had high sensitivity but poor
  specificity as markers of common disorders

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Lewis-Fernandez et al. (in press)

• Auditory and visual hallucinations reported by
  9.5 of community respondents with no DSM-IV
  psychiatric disorders
• High acculturation, and services utilization
  associated with psychotic symptom reports
• Psychotic symptoms associated with physical and
  emotional distress, traumatic exposures, suicidal
  ideation, even after controlling for psychiatric
  disorders-idiom of distress?

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European studies

• A wide research literature now exists on
  migration and psychosis and schizophrenia
• Psychoses are as commonly reported in Europe and
  U.K. as in U.S.
• Migrants/immigrants of all national origins have
  generally higher rates of psychoses and
  clinically diagnosed schizophrenia than native
  populations but with high variation African
  origin highest with a 9 rate in one U.K. study
• Contradiction as U.S. immigrants do not have
  higher schizophrenia spectrum diagnoses despite
  exhibiting putative psychotic symptoms
• However, U.S. minorities have highest rate of
  changed diagnoses

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Strategies for increasing diagnostic accuracy

• Reexamining your diagnostic approach
• Recognizing cultural variations in problem
  presentation and symptom expression
• Establishing comfort level

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Summary

• Clinician responsibility
• Awareness of historical record of mistreatment of
  African Americans
• Anticipating patient suspiciousness and confusion
• Being proactive in patient and family education
  about mental illness

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Research Agenda for DSM-V

• Edited by Kupfer, First Regier, included five
  chapters on progress made since DSM-IV and how
  this should be incorporated into DSM-V, including
  a chapter on diagnosis
• Its impact is limited by a number of issues
• -- Many concepts and proposed methodological
  changes remain highly theoretical, cannot be
  defined operationally and have limited practical
  value
• -- Omission of data supported by empirical
  studies (e.g. diagnostic bias resulting in
  systematic misdiagnosis).
• -- Inadequate theoretical or operational
  description of acculturation
• -- Limited application to proposed diagnostic
  systems or to clinical practice

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Recommendations for DSM-V

• We need much more focused research on ethnic
  issues
• Need to go beyond rhetoric
• Ethnicity needs to be defined more precisely
• Ethnic issues need to be depoliticized
• Provide crisp examples, practical guidelines,
  vignettes in key areas
• Do not continue to blend Hispanic/Latino
  populations into a single group recognize inter
  group and intra group variance
• Recommendations should be research-based and
  testable
• Use of brief, illustrative appendices may be
  helpful