No abstract

Most critiques of the psychiatric diagnostic system seem to presuppose a classical view of categorization; an alternative view of categorization, frequently called the prototype view, is emerging in the psychological literature. The present article represents an attempt to apply this alternative view to psychiatric diagnosis. The central thesis of this article is that while clinical diagnosis may appear "messy" and disordered from the classical perspective, it seems orderly and principled from the perspective of the prototype view. Two empirical investigations were conducted to document the utility of a change in views about psychiatric categorization systems and rules as they are used in practice, not with the pure, well-defined systems and rules that appear in the diagnostic manuals. The first investigation concerned the content and structure of the clinical features that trained psychiatrists commonly associate with patients from nine different diagnostic categories. The second investigation was directly concerned with problems of reliability and confidence in clinical diagnostic judgments. The results of both investigations provided strong support for the utility of the prototype view in this domain.

This paper critically reviews the process and outcome of an effort to enhance the cultural validity of DSM-IV and outlines recommendations to improve future diagnostic systems. An ordered presentation of the antecedents and the main phases of this developmental effort is followed by a content analysis of what was proposed and what was actually incorporated, and a conceptual analysis of underlying biases and their implications. The cultural effort for DSM-IV, spearheaded by a scholarly independent NIMH workgroup, resulted in significant innovations including an introductory cultural statement, cultural considerations for the use of diagnostic categories and criteria, a glossary of culture-bound syndromes and idioms of distress, and an outline for a cultural formulation. However, proposals that challenged universalistic nosological assumptions and argued for the contextualization of illness, diagnosis, and care were minimally incorporated and marginally placed. Although a step forward has been taken to introduce cultural elements in DSM-IV much remains to be done. Further culturally informed research is needed to ensure that future diagnostic systems incorporate a genuinely comprehensive framework, responsive to the complexity of health problems in increasingly multicultural societies.

Public mental health incorporates a number of strategies from mental well-being promotion to primary prevention and other forms of prevention. There is considerable evidence in the literature to suggest that early interventions and public education can work well for reducing psychiatric morbidity and resulting burden of disease. Educational strategies need to focus on individual, societal and environmental aspects. Targeted interventions at individuals will also need to focus on the whole population. A nested approach with the individual at the heart of it surrounded by family surrounded by society at large is the most suitable way to approach this. This Guidance should be read along with the European Psychiatric Association (EPA) Guidance on Prevention. Those at risk of developing psychiatric disorders also require adequate interventions as well as those who may have already developed illness. However, on the model of triage, mental health and well-being promotion need to be prioritized to ensure that, with the limited resources available, these activities do not get forgotten. One possibility is to have separate programmes for addressing concerns of a particular population group, another that is relevant for the broader general population. Mental health promotion as a concept is important and this will allow prevention of some psychiatric disorders and, by improving coping strategies, is likely to reduce the burden and stress induced by mental illness.

Latino or Spanish-speaking individuals constitute a substantial and growing population in the United States, in addition to their general presence, with cultural variations, throughout Latin America and the Iberian Peninsula. To respond to the needs of this population, a Spanish version of the Quality of Life Index (QLI-Sp) was developed. The QLI, in its various language versions, is a concise instrument for comprehensive, culture-informed, and self-rated assessment of health-rated quality of life. It is composed of 10 dimensions collated from the international literature, including aspects ranging from physical well-being to spiritual fulfillment, as well as a global perception of quality of life. Each item is to be rated on a 10-point line by Latino subjects according to their culture-informed understanding of that concept. The study samples included 60 Latino psychiatric patients (20 outpatient, 20 inpatient, and 20 partial hospitalization) and 20 Latino actively working hospital professionals. Mean time of completion was 2.4 minutes among health professionals and 3.6 minutes among patients. The vast majority of respondents (72% of patients and 1000% of professionals) judged the instrument as easy to use. The test-retest reliability correlation coefficient of the QLI-Sp mean score was .89. The discriminant validity of the QLI-Sp was documented by the highly significant difference obtained between the mean scores of the two samples selected to represent quite different levels of quality of life.

The outline for the Cultural Formulation (CF) introduced in DSM-IV does not present any method for collecting the required cultural information. The absence of specific guidelines and illustrative cases has hampered its wider use. This article offers a practical approach to preparing a Cultural Formulation as a component of culturally competent clinical care. We summarize the rationale for the four sections of the CF, describe the process of conducting culturally focused clinical interviews, and present examples of questions or lines of inquiry that can be used to collect the information needed to construct the CF. An online supplement provides case examples of cultural formulations applied to patients seen in the US.

The World Health Organization Short Disability Assessment Schedule (WHO DAS-S) is an instrument for clinicians' assessment and rating of difficulties in maintaining personal care, in performing occupational tasks and in functioning in relation to the family and the broader social context due to mental disorders. The WHO DAS-S was developed and underwent preliminarily testing in the context of two international field trials of the multiaxial presentation of ICD-10 for use in adult psychiatry. The instrument was found to be useful, user-friendly and reasonably reliable for use by clinicians belonging to different schools of psychiatry and psychiatric traditions. Further work on the WHO DAS-S should include development of national adaptations of the instrument, studies of concurrent validity of the instrument and modification of the instrument to accommodate changes in the next edition of the International Classification of Impairments, Disabilities and Handicaps (ICIDH).

The Multicultural Quality of Life Index is a brief and culturally informed instrument that appears to be easy to complete, reliable, internally consistent and valid.