Research Commentary [9] August 2017

Aug 1, 2017

This review focuses on mental health screening tools in multiple languages.

A number of screening tools are available to detect common mental health disorders, but few have been specifically developed for Culturally and Linguistically Diverse (CALD) populations. Cross-cultural application of a screening tool requires that its validity be assessed against a gold standard diagnostic interview. Our new website has a collection of a list of mental health screening tools in multiple languages for health practitioners working in primary, secondary and community health settings that . The tools are applicable to child and youth, adult and older adult populations. Some have been validated for reliability.

Commentary provided by Dr Annette Mortensen, eCALD® Project Manager: Research & Development

The following are articles reviewed: 

Article 1: Validated Screening Tools for Common Mental Disorders in Low and Middle Income Countries: A Systematic Review.

A wide range of screening tools is available to detect common mental health disorders (CMDs), but few have been specifically developed for low and middle income (LMIC) populations (or for CALD populations in high income countries). There is concern that using tools developed for high-income country populations will miss cases in LMIC. In sub-Saharan Africa, for example, distress is believed to be more commonly expressed through somatic symptoms and local idioms. Although mental health disorders are prevalent worldwide, clinical presentation does differ between countries. For example, previous validations of the Edinburgh postnatal depression scale (EPDS) in LMIC have generally found lower optimum cut-off scores than those recommended for the populations in which the tools were developed. This may be due to cross-cultural differences in the somatisation of symptoms and the expression of emotional distress, leading to under-recognition or misidentification of psychiatric morbidity.

Cross-cultural application of a screening tool requires that its validity be assessed against a gold standard diagnostic interview. Ali et al’s (2016) study is the first to review the brief screening tools for all common mental health disorders across all LMIC populations. The study highlights the importance of local validation. Many of the best performing tools were purposely developed for a specific population.

Of the tools that have been validated in multiple settings, the authors broadly recommend using the SRQ-20 to screen for general CMDs, the GHQ-12 for CMDs in populations with physical illness, the HADS-D for depressive disorders, the PHQ-9 for depressive disorders in populations with good literacy levels, the EPDS for perinatal depressive disorders, and the HADS-A for anxiety disorders. The authors recommend that, wherever possible, a chosen screening tool should be validated against a gold standard diagnostic assessment in the specific context in which it will be employed. 

Authors: Ali, G-C., Ryan, G., De Silva, M.J.

Citation: Ali, G-C., Ryan, G., De Silva, M.J. (2016). Validated Screening Tools for Common Mental Disorders in Low and Middle Income Countries: A Systematic Review. PLoS ONE, 11(6), e0156939.

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Article 2: Implementation of the Cultural Formulation through a newly developed Brief Cultural Interview: Pilot data from the Netherlands. 

The Outline for a Cultural Formulation (OCF) has remained underutilised in clinical practice since its publication in the DSM-IV in 1994. In the Netherlands, a Cultural Interview (CI) was developed in 2002 as a tool to facilitate the use of the OCF in clinical practice. The time needed to conduct the interview, however, prevented its systematic implementation within mental health institutions. This article presents the development of a shortened and adapted version, the Brief Cultural Interview (BCI), and a pilot study on the feasibility, acceptability, and utility of its implementation with refugee and asylum seeking patients in a Dutch centre for transcultural psychiatry. The results of the study show that the brief version scores better on feasibility and acceptability, while utility for clinical practice remains similar to that of the original CI. These results support the systematic use of the OCF in psychiatric care for a culturally diverse patient population through the application of a relatively brief cultural interview.

A secondary finding of the study is that patients' cultural identity, such as place of origin, ethnicity, acculturation, and self-image, was considered by clinicians to be more useful in treatment planning than their cultural explanations of illness. The BCI explored the meaning of cultural identity for the person is in more depth than the DSM-IV OCF.  However, because of the limited number of participants in this study, more research on differences between the usefulness of cultural identity compared to cultural explanations of illness is required in order to make more firm statements, or confirm the author’s results. 

The BCI proved to be a practical tool, partly because of its relatively limited length and good comprehensibility. In the Dutch centre for transcultural psychiatry, the outcomes of the BCI have been incorporated into the standard clinical assessment and are included in patients’ medical files. Since the completion of the research project in 2006, the role of the BCI in the centre has increased. In 2010, 99% of patient files included a BCI.

Authors: Groen, S.P.N., Richters, A., Laban, C.J. Deville, W.L.J.M. 

Citation: Groen, S.P.N., Richters, A., Laban, C.J. Deville, W.L.J.M. (2017). Implementation of the Cultural Formulation through a newly developed Brief Cultural Interview: Pilot data from the Netherlands. Transcultural Psychiatry, 54 (1) 3–22. 

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Article 3: Feasibility, acceptability and clinical utility of the Cultural Formulation Interview: mixed-methods results from the DSM-5 international field trial.

There is a need for clinical tools to identify cultural issues in diagnostic assessment. The DSM-IV Outline for Cultural Formulation (OCF) is a conceptual framework that helps clinicians identify the impact of culture on illness and care during a clinical evaluation. The OCF is widely used in clinical training and cultural competence initiatives. However, its implementation in routine care has proved challenging.  In response, the American Psychiatric Association’s DSM-5 Cross-Cultural Issues Subgroup (DCCIS) developed the Cultural Formulation Interview (CFI) to operationalise the OCF for routine use in the clinical assessment of any patient. The CFI instruments comprise an initial assessment interview (core CFI), an informant interview for collateral information and 12 supplementary modules that expand on these basic assessments. The core CFI consists of an introduction, open-ended questions for patients and instructions to clinicians for each question. 

The DSM-5 CFI field trial was the first international study to examine clinician and patient perceptions of the feasibility, acceptability and clinical utility of a cultural assessment interview designed for use in routine clinical practice in diverse cross-national settings. The international trial included 318 patients and 75 clinicians over 11 sites in six countries (Canada, Kenya, The Netherlands, Peru, USA). The sites chosen aimed to include diverse cultural populations and types of out-patient services (general community, immigrant/refugee and ethnic-focus clinics).The Cultural Formulation Interview was found to be a feasible, acceptable and useful cultural assessment tool in routine clinical practice and was included in the DSM-5. Clinician feasibility ratings were significantly lower than patient ratings and other clinician-assessed outcomes. However, after administering one CFI, clinician feasibility ratings improved significantly and subsequent interviews required less time. 

Findings suggest that 2 hours of training followed by experience administering a few interviews may be sufficient to address clinicians’ concerns about feasible use of the instrument, even in a diverse sample of provider disciplines and of cultural competence experience across sites. 

Authors: Lewis-Fernandez  et al.

Citation: Lewis-Fernandez et al., (2017). Feasibility, acceptability and clinical utility of the Cultural Formulation Interview: mixed-methods results from the DSM-5 international field trial. The British Journal of Psychiatr, 1–8. doi: 10.1192/bjp.bp.116.193862 

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Article 4: Reliability and validity of the Chinese version of the Patient Health Questionnaire (PHQ-9) in the general population.

The prevalence of major depression has varied from 2.07% to 6.87% in the Chinese population. In China, there are only 1.46 psychiatrists per 100,000 people and 15 beds per 100,000 people for the treatment of mental illness. Due to the scarce mental health resources available, many patients with mental health disorders are undertreated and underreported. Studies have shown that the identification rate of depression ranged from as low as 13.0% to 31.8% in a general hospital in China. It can be expected that the identification rate in the general population is even lower. Thus, the detection of depression and the dissemination of treatment in the general population are very important to reduce the burden of the disease. 

The aim of this study was to evaluate the reliability and the validity of the Chinese version of the PHQ-9 in the general population in China; the Chinese version of the Mini International Neuropsychiatric Interview (MINI) was used as the gold standard for major depression diagnosis. Compared with other instruments for screening depression, the Patient Health Questionnaire (PHQ)-9 satisfies five practical considerations, which include brevity, self-administered, multipurpose, in the public domain, and easy to score. The study found that the Chinese version of the PHQ-9 is a valid and efficient tool for screening depression in the general Chinese population, with a recommended cut-off score of 7 or more. 

Author: Wang et al. 

Citation: Wang et al., (2014). Reliability and validity of the Chinese version of the Patient Health Questionnaire (PHQ-9) in the general population.  General Hospital Psychiatry 36, 539–544.

References:

Blazer, D.G. & Kessler, R.C. (2013). The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey. Age (years), 151, 979–86.

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Article 5: A validation study of the Hong Kong version of Montreal Cognitive Assessment (HK-MoCA) in Chinese older adults in Hong Kong.

The purpose of this study was to validate the Hong Kong version of the Montreal Cognitive Assessment (HK-MoCA) in identification of mild cognitive impairment and dementia in Chinese older adults. The study setting was a cognition clinic and memory clinic of a public hospital in Hong Kong.  A total of 272 participants (dementia, n=130; mild cognitive impairment, n=93; normal controls, n=49) aged 60 years or above were assessed using HK-MoCA. The study verified that the HK-MoCA has high diagnostic accuracy for detection of dementia (sensitivity, 92.3%; specificity, 91.8%). P

The HK-MoCA is a useful cognitive screening instrument for use in Chinese older adults in Hong Kong. A score of less than 22 should prompt further diagnostic assessment. It has comparable sensitivity with the Cantonese version of Mini- Mental State Examination for detection of mild cognitive impairment. It is brief and feasible to conduct in the clinical setting, and can be completed in less than 15 minutes. The HK-MoCA provides an attractive alternative screening instrument to Mini-Mental State Examination which has ceiling effect (i.e. may fail to detect mild/moderate cognitive impairment in people with high education level or premorbid intelligence) and needs to be purchased due to copyright issues. 

Authors: Yeung, P.Y., Wong, L.L., Chan, C.C., Leung, J.L.M. & Yung, C.Y. 

Citation: Yeung, P.Y., Wong, L.L., Chan, C.C., Leung, J.L.M. & Yung, C.Y. (2014). A validation study of the Hong Kong version of Montreal Cognitive Assessment (HK-MoCA) in Chinese older adults in Hong Kong. Hong Kong Med J, 20 (6), 504-10. 

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