Current Controversies in Diagnostic Current Controversies in Diagnostic Accuracy of DSM Disorders inAccuracy of DSM Disorders in

Minority GroupsMinority Groups

3737thth Semi-annual Substance Abuse Semi-annual Substance Abuse Research Consortium (SARC)Research Consortium (SARC)

May 30, 2008May 30, 2008William A. VegaWilliam A. Vega

ProfessorProfessorDavid Geffen School of MedicineDavid Geffen School of Medicine

UCLAUCLA

Aims of presentationAims of presentation To briefly review the conceptual and To briefly review the conceptual and

methodological issues bearing on the methodological issues bearing on the reliability and validity of research and reliability and validity of research and clinical diagnoses of drug disordersclinical diagnoses of drug disorders

To examine diagnostic inconsistencies To examine diagnostic inconsistencies between U.S. ethnic and demographic between U.S. ethnic and demographic subgroupssubgroups

To briefly review emerging evidence of To briefly review emerging evidence of language and cultural effects on language and cultural effects on symptoms and diagnosessymptoms and diagnoses

Make recommendations to improve Make recommendations to improve diagnoses and clinical treatmentdiagnoses and clinical treatment

CultureCulture

““A shared set of beliefs, norms, or A shared set of beliefs, norms, or values that will influence the values that will influence the

meaning given to life events and meaning given to life events and experiences”experiences”

Schraufnagel TJ. Gen Hosp Psychiatry. 2006;28(1):27.

Culture and mental healthCulture and mental health Culture defines the meaning and acceptability of Culture defines the meaning and acceptability of

drug use behaviordrug use behavior Behavior is controlled by behavior normsBehavior is controlled by behavior norms Families are the primary social institution for Families are the primary social institution for

emotional support and establishing behavior emotional support and establishing behavior expectations in children expectations in children

Society also influences behavior by providing Society also influences behavior by providing opportunities for human development and linking opportunities for human development and linking families and individuals to social institutions but the families and individuals to social institutions but the level of influence varies widelylevel of influence varies widely

Large sectors of the minority populations are socially Large sectors of the minority populations are socially isolated isolated

Drug use patterns highly idiosyncratic by ethnic Drug use patterns highly idiosyncratic by ethnic groups in U.S. and across different societies groups in U.S. and across different societies

Aspects of Cultural IdentityAspects of Cultural Identity

Accultur-ationLevel

Degree of

affiliation with all these

aspects

Migration History

Other Identified groups

EducationSocio-

economicStatus

Religious/SpiritualBeliefs

SexualOrientation

MaritalStatus

Age

Gender

Language

CountryOf

Origin

Race

Ethnicity

Culture

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.

Tensions in the DSM approachTensions in the DSM approach The DSM is a descriptive manual of disorders and The DSM is a descriptive manual of disorders and

is atheoretical and complex with symptom is atheoretical and complex with symptom overlapoverlap

The DSM is supposed to be a framework for The DSM is supposed to be a framework for researchresearch

The disorders are determined by committee The disorders are determined by committee action and have expanded exponentially over the action and have expanded exponentially over the past 30 years from a handful to hundredspast 30 years from a handful to hundreds

Etiologic information is supposed to inform the Etiologic information is supposed to inform the formation of the categories but we have no formation of the categories but we have no biologic markers of disorders available and no biologic markers of disorders available and no confirmed causal modelsconfirmed causal models

Language is the primary bases for establishing a Language is the primary bases for establishing a diagnosis – reliance on effective communication diagnosis – reliance on effective communication

genomegenomeprotein expressionprotein expression

neural circuitsneural circuits

DrugsDrugssocialsocial

conductconduct

Systems operating in the etiology ofdrug addiction and mental illnessesSystems operating in the etiology ofdrug addiction and mental illnesses

MENTAL MENTAL ILLNESSESILLNESSES

“ “ The question is whether different The question is whether different genotypes have a different genotypes have a different

relationship to the phenotype in relationship to the phenotype in

different environments.”different environments.”

Cooper, R.S. (2003) Gene-environments Cooper, R.S. (2003) Gene-environments interactionsinteractions

and the etiology of common complex disease. and the etiology of common complex disease. Ann Inter Med 139:437-440Ann Inter Med 139:437-440

Ph

eno

typ

e

Exposure

Mexico USA

GVA

GVP

GVA

GVP

Context Dependence: Gene-Environment Interaction ModelContext Dependence: Gene-Environment Interaction Model

Adapted from Cooper, R.S. (2003). Annals of Internal Medicine, 139:437-440

GVA = Gene Variant AbsentGVP = Gene Variant Present

Lifetime DSM-IV Rates (%) of Substance Disorders Lifetime DSM-IV Rates (%) of Substance Disorders in Mexican Women and in Mexican Women and

Mexican-origin Women in U.S.Mexican-origin Women in U.S.

11 NESARC. NESARC. 22 from M. Medina-Mora et al., in press. from M. Medina-Mora et al., in press.

U.S.1

Mexico2 Immigrants U.S. born

Alcohol abuse 0.4 1.0 8.7

Alcohol dependence 0.5 1.7 11.0

Drug abuse 0.0 0.6 5.2

Drug dependence 0.1 0.3 3.2

Nicotine dependence 0.9 1.5 9.8

Lifetime DSM-IV Rates (%) of Substance Disorders Lifetime DSM-IV Rates (%) of Substance Disorders in Mexican Men and Mexican-origin Men in U.S.in Mexican Men and Mexican-origin Men in U.S.

11 NESARC. NESARC. 22 from M. Medina-Mora et al., in press. from M. Medina-Mora et al., in press.

U.S.1

Mexico2 Immigrants U.S. born

Alcohol abuse 4.9 15.4 25.2

Alcohol dependence 8.8 9.6 19.4

Drug abuse 2.3 1.8 12.0

Drug dependence 0.7 0.5 4.5

Nicotine dependence 2.2 5.1 10.2

SUD and EthnicitySUD and Ethnicity

U.S. has the highest 12-month prevalence of U.S. has the highest 12-month prevalence of substance (DSM-IV) disorders (3.8%) in the substance (DSM-IV) disorders (3.8%) in the WHO MH Surveys across 14 countries WHO MH Surveys across 14 countries (excepting Ukraine), and 13.5 times higher (excepting Ukraine), and 13.5 times higher then Spain!then Spain!

Drug dependence is not more pervasive in Drug dependence is not more pervasive in U.S. ethnic groups than in WhitesU.S. ethnic groups than in Whites

Reactivity to cumulative adversity is lower Reactivity to cumulative adversity is lower among ethnic minorities- better coping or among ethnic minorities- better coping or displacement to other medical disorders?displacement to other medical disorders?

Methods issuesMethods issues Are substance disorders best measured as Are substance disorders best measured as

categorical or dimensional phenomena, or categorical or dimensional phenomena, or a combination of the two?a combination of the two?

What statistical procedure can best What statistical procedure can best accomplish this?accomplish this?

What are the implications for clinical What are the implications for clinical diagnosesdiagnoses

Will resolution differ by drug phenotypeWill resolution differ by drug phenotype type?type?Are drug disorder phenotypes influenced by Are drug disorder phenotypes influenced by

culture?culture?

Sources of bias in the diagnostic process: Sources of bias in the diagnostic process: low concordance and misdiagnoseslow concordance and misdiagnoses

Patient ethnicityPatient ethnicity Patient language usePatient language use Clinician ethnicityClinician ethnicity Clinician language useClinician language use Clinician trainingClinician training Clinician awareness of stereotyping effects Clinician awareness of stereotyping effects

on diagnostic processon diagnostic process Etic vs. emic criteria: semantic relevance Etic vs. emic criteria: semantic relevance

and common meaningand common meaning

Cross-cultural reliability of Cross-cultural reliability of diagnostic criteriadiagnostic criteria

What do we know about the phenomenology of What do we know about the phenomenology of diagnoses for drug dependence?diagnoses for drug dependence?

How might it be influenced by ethnicity, nativity, How might it be influenced by ethnicity, nativity, language use, sex, and SES?language use, sex, and SES?

Is their sufficient information to establish the Is their sufficient information to establish the validity of substance abuse and dependence validity of substance abuse and dependence criteria?criteria?

How does the life course of SUD onset, How does the life course of SUD onset, persistence, and remission differ by ethnicity?persistence, and remission differ by ethnicity?

How do dual diagnoses, subsyndromal, and How do dual diagnoses, subsyndromal, and orphan disorder patterns differ by ethnicity and orphan disorder patterns differ by ethnicity and ethnic subgroup factors? ethnic subgroup factors?

Culturally laden termsCulturally laden terms

Evaluating meaning of “loss of Evaluating meaning of “loss of control” and “craving”control” and “craving”

Can you preserve the equivalence of Can you preserve the equivalence of these diagnostic terms cross- these diagnostic terms cross- culturally?culturally?

Risk taking and impulsivity have Risk taking and impulsivity have been shown to vary greatly by been shown to vary greatly by nativity among Latinosnativity among Latinos

Dual diagnosesDual diagnoses Are current criteria optimal diagnoses of dual Are current criteria optimal diagnoses of dual

diagnoses?diagnoses? Does dual diagnoses require all criteria for a SUD Does dual diagnoses require all criteria for a SUD

to be clinically meaningful and treatable?to be clinically meaningful and treatable? What about binge vs continuous substance use, What about binge vs continuous substance use,

which may be culturally influenced even within which may be culturally influenced even within ethnic groups?ethnic groups?

Should full criteria be met for a non addictive Should full criteria be met for a non addictive disorder to establish the presence of a substance disorder to establish the presence of a substance induced condition? induced condition?

How do phenomenological dual diagnoses How do phenomenological dual diagnoses patterns vary by ethnicity?patterns vary by ethnicity?

NLAAS dual diagnoses rates for U.S. NLAAS dual diagnoses rates for U.S. national sample of Latinosnational sample of Latinos

Any alcohol abuse/dependence with Any alcohol abuse/dependence with or without drug dependence, and a or without drug dependence, and a co-occurring non-addictive DSM-IV co-occurring non-addictive DSM-IV disorderdisorder

Total for immigrant women 0.68%,Total for immigrant women 0.68%,men 5.25%men 5.25%

Total for U.S. born women 7.33%, Total for U.S. born women 7.33%, men 16.22% men 16.22%

Confounds in the diagnostic Confounds in the diagnostic process: Ethnicity and psychosesprocess: Ethnicity and psychoses

Putative psychotic symptoms are Putative psychotic symptoms are commonly reported by Latinos who are commonly reported by Latinos who are medical patients, psychiatric patients, or medical patients, psychiatric patients, or non-symptomaticnon-symptomatic

Incongruent psychotic features are Incongruent psychotic features are frequently reported by depressed Latino frequently reported by depressed Latino patientspatients

Negligible research available about Negligible research available about expressions of “psychotic depression” in expressions of “psychotic depression” in ethnic groups ethnic groups

Population studies of African Population studies of African

Americans Americans Reported from a registry study of a cohort born a Reported from a registry study of a cohort born a

Oakland children’s hospital disproportionately high Oakland children’s hospital disproportionately high rates of schizophrenia among African Americans rates of schizophrenia among African Americans compared to whites two decades later based on compared to whites two decades later based on treatment records; Bresnhan et al., Int. J. Epi., 2007 treatment records; Bresnhan et al., Int. J. Epi., 2007

ECA studies failed to find major differences in rates ECA studies failed to find major differences in rates by ethnic group for depression or schizophrenia, by ethnic group for depression or schizophrenia, and WHO estimated 1% rate in review of and WHO estimated 1% rate in review of international sitesinternational sites

Limitation: psychotic disorders notoriously difficult Limitation: psychotic disorders notoriously difficult to diagnose in clinical (usual care) and community to diagnose in clinical (usual care) and community studies due to poor inter-rater reliability, hiatus on studies due to poor inter-rater reliability, hiatus on field ascertainmentfield ascertainment

Ethnicity and language of both patients and Ethnicity and language of both patients and clinicians are confounders in diagnostic studiesclinicians are confounders in diagnostic studies

Knowing your patient:Knowing your patient:William Lawson, M.D.William Lawson, M.D.

Patient disclosurePatient disclosure Patient engagementPatient engagement Cultural nuances in presentationCultural nuances in presentation Social factorsSocial factors

Accurate diagnosis: Accurate diagnosis: Steven Strakowski, M.D.Steven Strakowski, M.D.

Common trouble spots in diagnosing Common trouble spots in diagnosing African American patients for African American patients for schizophrenia; error rate 44% vs. 18% for schizophrenia; error rate 44% vs. 18% for whites whites

Clinician tendencies regarding first rank Clinician tendencies regarding first rank symptoms in the diagnostic processsymptoms in the diagnostic process

Overvaluing substance use, hallucinations Overvaluing substance use, hallucinations and delusions and undervaluing or not and delusions and undervaluing or not fully assessing mood symptomsfully assessing mood symptoms

Improving care for African Improving care for African American patientsAmerican patients

Goals:Goals:– Overcoming documented problems in Overcoming documented problems in

diagnosis and medication diagnosis and medication – Improving patient evaluationImproving patient evaluation– Improving effective communicationImproving effective communication– Improving complianceImproving compliance

Recommendations of recent expert Recommendations of recent expert reviewsreviews

Improve and disseminate knowledge Improve and disseminate knowledge about culturally competent care about culturally competent care

Rapid information transfer to Rapid information transfer to practitionerspractitioners

Identify and address documented Identify and address documented disparities in quality of caredisparities in quality of care

Increase accountability through Increase accountability through monitoring outcomes of caremonitoring outcomes of care

““Be aware of personal bias and Be aware of personal bias and countertransference, and keep in mind that countertransference, and keep in mind that a patient is first and foremost an individual. a patient is first and foremost an individual.

Do not let cultural-specific information Do not let cultural-specific information obscure the individual patient, which can obscure the individual patient, which can occur if the healthcare provider treats the occur if the healthcare provider treats the

information stereotypically and acts as if all information stereotypically and acts as if all members of an ethnic category must members of an ethnic category must

behave and believe in the same fashion.”behave and believe in the same fashion.”A. HardwoodA. Hardwood

Vega et al. Nerv. Ment. Dis. Vega et al. Nerv. Ment. Dis. 20062006

Putative psychotic symptoms commonly reported in Putative psychotic symptoms commonly reported in community sample of Mexican origin people in community sample of Mexican origin people in California California

Rates highest among U.S. born – lower among Rates highest among U.S. born – lower among immigrantsimmigrants

Psychotic symptoms increased if psychiatric disorders Psychotic symptoms increased if psychiatric disorders are comorbid and are highest if multiple disorders are comorbid and are highest if multiple disorders reportedreported

Prevalence of mood disorders was 15% in U.S. born Prevalence of mood disorders was 15% in U.S. born women with no psychotic symptoms, and 38% if women with no psychotic symptoms, and 38% if reporting psychotic symptomsreporting psychotic symptoms

First rank symptoms had high sensitivity but poor First rank symptoms had high sensitivity but poor specificity as markers of common disordersspecificity as markers of common disorders

Lewis-Fernandez et al. (in Lewis-Fernandez et al. (in press)press)

Auditory and visual hallucinations reported Auditory and visual hallucinations reported by 9.5% of community respondents with by 9.5% of community respondents with no DSM-IV psychiatric disordersno DSM-IV psychiatric disorders

High acculturation, and services utilization High acculturation, and services utilization associated with psychotic symptom associated with psychotic symptom reportsreports

Psychotic symptoms associated with Psychotic symptoms associated with physical and emotional distress, traumatic physical and emotional distress, traumatic exposures, suicidal ideation, even after exposures, suicidal ideation, even after controlling for psychiatric disorders-idiom controlling for psychiatric disorders-idiom of distress? of distress?

European studies European studies A wide research literature now exists on A wide research literature now exists on

migration and psychosis and schizophreniamigration and psychosis and schizophrenia Psychoses are as commonly reported in Europe Psychoses are as commonly reported in Europe

and U.K. as in U.S.and U.K. as in U.S. Migrants/immigrants of all national origins have Migrants/immigrants of all national origins have

generally higher rates of psychoses and clinically generally higher rates of psychoses and clinically diagnosed schizophrenia than native populations diagnosed schizophrenia than native populations but with high variation –African origin highest but with high variation –African origin highest with a 9% rate in one U.K. studywith a 9% rate in one U.K. study

Contradiction as U.S. immigrants do not have Contradiction as U.S. immigrants do not have higher schizophrenia spectrum diagnoses despite higher schizophrenia spectrum diagnoses despite exhibiting putative psychotic symptoms exhibiting putative psychotic symptoms

However, U.S. minorities have highest rate of However, U.S. minorities have highest rate of changed diagnoseschanged diagnoses

Strategies for increasing diagnostic Strategies for increasing diagnostic accuracyaccuracy

Reexamining your diagnostic approachReexamining your diagnostic approach

Recognizing cultural variations in Recognizing cultural variations in problem presentation and symptom problem presentation and symptom expressionexpression

Establishing comfort levelEstablishing comfort level

SummarySummary

Clinician responsibility Clinician responsibility Awareness of historical record of Awareness of historical record of

mistreatment of African Americansmistreatment of African Americans Anticipating patient suspiciousness Anticipating patient suspiciousness

and confusionand confusion Being proactive in patient and family Being proactive in patient and family

education about mental illnesseducation about mental illness

““Research Agenda for DSM-V”Research Agenda for DSM-V”

Edited by Kupfer, First & Regier, included five chapters on Edited by Kupfer, First & Regier, included five chapters on progress made since DSM-IV and how this should be progress made since DSM-IV and how this should be incorporated into DSM-V, including a chapter on diagnosisincorporated into DSM-V, including a chapter on diagnosis

Its impact is limited by a number of issues: Its impact is limited by a number of issues: -- Many concepts and proposed methodological changes remain -- Many concepts and proposed methodological changes remain

highly theoretical, cannot be defined operationally and have highly theoretical, cannot be defined operationally and have limited practical valuelimited practical value

-- Omission of data supported by empirical studies (e.g. -- Omission of data supported by empirical studies (e.g. diagnostic bias resulting in systematic misdiagnosis).diagnostic bias resulting in systematic misdiagnosis).

-- Inadequate theoretical or operational description of -- Inadequate theoretical or operational description of “acculturation”“acculturation”

-- Limited application to proposed diagnostic systems or to -- Limited application to proposed diagnostic systems or to clinical practiceclinical practice

Recommendations for DSM-VRecommendations for DSM-V We need much more focused research on ethnic We need much more focused research on ethnic

issuesissues Need to go beyond rhetoricNeed to go beyond rhetoric Ethnicity needs to be defined more preciselyEthnicity needs to be defined more precisely Ethnic issues need to be depoliticizedEthnic issues need to be depoliticized Provide “crisp” examples, practical guidelines, Provide “crisp” examples, practical guidelines,

“vignettes” in key areas“vignettes” in key areas Do not continue to blend Hispanic/Latino populations Do not continue to blend Hispanic/Latino populations

into a single group – recognize inter group and intra into a single group – recognize inter group and intra group variancegroup variance

Recommendations should be research-based and Recommendations should be research-based and testabletestable

Use of brief, illustrative appendices may be helpful Use of brief, illustrative appendices may be helpful