Current Controversies in Diagnostic Accuracy of DSM Disorders in Minority Groups

1. 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

2. 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

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. 2006;28(1):27.

4. 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

5. 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; 2006:10.

6. 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

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 139:437-440

9. Context Dependence: Gene-Environment Interaction Model GVP Phenotype GVP GVA GVA Mexico USA Exposure GVA = Gene Variant Absent GVP = Gene Variant Present Adapted from Cooper, R.S. (2003). Annals of Internal Medicine, 139:437-440

10. 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.

11. 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.

12. 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?

15. 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?

16. 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

17. 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?

18. 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

19. 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?

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%

21. 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

22. Population studies of African Americans • Reported from a registry study of a cohort born a Oakland children’s 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

23. Knowing your patient:William Lawson, M.D. • Patient disclosure • Patient engagement • Cultural nuances in presentation • Social factors

24. 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

25. Improving care for African American patients • Goals: • Overcoming documented problems in diagnosis and medication • Improving patient evaluation • Improving effective communication • Improving compliance

26. 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

27. “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

28. 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

29. 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?

30. 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

31. Strategies for increasing diagnostic accuracy • Reexamining your diagnostic approach • Recognizing cultural variations in problem presentation and symptom expression • Establishing comfort level

32. 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

33. “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

34. 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