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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

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Promoting Cultural Competence
The Center of Excellence for Cultural Competence Leads the Diagnostic and
Statistical Manual of Mental Disorders (DSM)-5 Cultural Formulation Field Trial

The Center of Excellence for Cultural Competence (CECC) at the New York State Psychiatric Institute is proud to lead the American Psychiatric Association’s (APA) DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) field trial for the Cultural Formulation Interview (CFI). The CFI operationalizes for clinicians the Outline for Cultural Formulation that was included in DSM-IV. The DSM-5 CFI study is an international collaboration with field sites in the United States, India, Peru, the Netherlands, Canada, and Kenya. Each site is supporting its own trial with expected APA support to conduct overall data analysis. At the CECC, Roberto Lewis-Fernández, Medical Doctor (MD) is the Principal Investigator with Neil Krishan Aggarwal, MD as co-Investigator. Doctor. Aggarwal is supported by the National Institutes of Mental Health’s T-32 training grant.

Unlike the standard patient history, whose agenda of topics to explore is usually set by the clinician, the Cultural Formulation attempts to address problems from the patient’s standpoint. The Cultural Formulation is a systematic method for assessing cultural aspects of the patient’s presentation and treatment expectations in order to make clinical care more culturally appropriate. This type of framework may help to prevent errors in diagnosis and treatment planning. It may also aid clinicians in determining when best to call for interpreters and cultural brokers. From the public health perspective, it may potentially serve to reduce racial and ethnic disparities in mental health care.

In the past, the Cultural Formulation suffered from several limitations. Many busy clinicians could not find ways of asking relevant questions from the brief description provided in DSM-IV. Even though mental health journals have published detailed case examples, the lack of a standardized format has hindered the Cultural Formulation’s use as a clinical and research instrument. As a consequence, the DSM-IV Cultural Formulation has not stimulated the types of outcomes-based research for which it had been intended. Important research questions include, for example, whether the Cultural Formulation enhances the quality of treatment and encourages culturally appropriate care. This field trial will help us address these types of limitations.
In response, the CECC hopes that a questionnaire of fourteen questions developed with an international consortium of mental health providers will formalize the process of evaluating culture in clinical care. Questions are asked about: (1) the patient’s identity, (2) the patient’s understandings about the cause, mechanism, label, and level of impairment relating to the presenting problem, (3) the role of the patient’s circumstances in improving or worsening the presenting problem, including the contributions of family, friends, and significant others, (4) the patient’s views on types of help received in the past and his/her current expectations for treatment, (5) the barriers to treatment which could potentially hinder current care, (6) and the patient’s perspective on whether and how the cultural background of the clinician will affect care. By testing the CFI’s feasibility (can this be done?), acceptability (do users like this?), and clinical utility (is this helpful?), the CECC and its team of international investigators hope to develop concrete recommendations for DSM-5 so that all mental health clinicians can assess for cultural factors in clinical care. Supplementary modules are being developed for use of the CFI in children, adolescents, and the elderly.

The CECC is also managing the logistics of the field trial. A training protocol has been standardized whereby each clinician will receive typed guidelines providing background information for each question, watch a video of a cultural expert administering the CFI, and practice asking the questions in an interactive environment. The ten sites hope to enroll 300 patients in one of the largest field trials for cultural psychiatry. The CECC will coordinate data analysis for all sites in conjunction with the American Psychiatric Association. We hope to provide periodic updates as the study approaches completion in June 2012.

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