Title: Current Controversies in Diagnostic Accuracy of DSM Disorders in Minority Groups
1Current 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
2Aims 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
3- 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.
4Culture 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
5Aspects 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.
6Tensions 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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8 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
9Context 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
10Lifetime 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. -
11Lifetime 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. -
12SUD 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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15Methods 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?
16Sources 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
17Cross-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?
18Culturally 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
19Dual 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?
20 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
21Confounds 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
22Population 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
23Knowing your patientWilliam Lawson, M.D.
- Patient disclosure
- Patient engagement
- Cultural nuances in presentation
- Social factors
24Accurate 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
25Improving care for African American patients
- Goals
- Overcoming documented problems in diagnosis and
medication - Improving patient evaluation
- Improving effective communication
- Improving compliance
26Recommendations 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
27Be 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
28Vega 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
29Lewis-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?
30European 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
31Strategies for increasing diagnostic accuracy
- Reexamining your diagnostic approach
- Recognizing cultural variations in problem
presentation and symptom expression - Establishing comfort level
32Summary
- 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
33Research 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
34Recommendations 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