Using the Cultural Formulation to Resolve Uncertainty in Diagnoses of Psychosis Among Ethnoculturally Diverse Patients

Objective: The aim of the study was to assess the impact of systematic use of the DSM-IV-TR cultural formulation on diagnoses of psychotic disor- ders among patients of ethnic minority and immigrant backgrounds re- ferred to a cultural consultation service (CCS) in Canada. 

Methods: The study entailed a review of medical records and case conference tran- scripts of 323 patients seen in a ten-year period at the CCS to determine factors associated with change in the diagnosis of psychotic disorders by the CCS. Logistic regression analysis was used to identify variables asso- ciated with changes in diagnosis. 

Results: A total of 34 (49%) of the 70 cas- es with an intake (referral) diagnosis of a psychotic disorder were rediag- nosed as nonpsychotic disorders, whereas only 12 (5%) of the 253 cases with an intake diagnosis of a nonpsychotic disorder were rediagnosed as a psychotic disorder (p<.001). Major depression, posttraumatic stress dis- order (PTSD), adjustment disorder, and bipolar affective disorder were the common disorders diagnosed with use of the cultural formulation. Rediagnosis of a psychotic disorder as a nonpsychotic disorder was sig- nificantly associated with being a recent arrival in Canada (odds ratio [OR]=6.05, 95% confidence interval [CI]=1.56–23.46, p=.009), being non- black (OR=3.72, CI=1.03–13.41, p=.045), and being referred to the CCS by nonmedical routes (such as social work or occupational therapy) (OR=3.23, CI=1.03–10.13, p=.044). 

Conclusions: Misdiagnosis of psychot- ic disorders occurred with patients of all ethnocultural backgrounds. PTSD and adjustment disorder were misidentified as psychosis among immigrants and refugees from South Asia. Studies are needed that com- pare clinical outcomes of use of cultural consultation with outcomes from use of other cultural competence models. (Psychiatric Services 63:147–153, 2012; doi: 10.1176/

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Home of the Culturally Adapted Psychoeducation project for families of patients with first-episode psychosis and The Culture and Psychosis Working Group