Effects of a culturally sensitive assessment on symptom profiles in native Dutch and Moroccan patients with a first psychosis referral.

Previous studies have reported a higher incidence of psychosis in Moroccan immigrants in the Netherlands than among native-born residents. However, this disparity was substantially attenuated when cultural differences in symptom presentation were taken into account. To better understand the impact of different diagnostic procedures on incidence rates, we examined the effects of the use of a culturally sensitive diagnostic interview, compared to a standard semi-structured diagnostic interview, on symptom profiles among Moroccan immigrant and native Dutch patients in the Netherlands. A total of 26 Dutch and 26 Moroccan patients referred with a possible first psychosis diagnosis were interviewed twice: once with the standard version and once with a culturally adapted version of the Comprehensive Assessment of Symptoms and History questionnaire (CASH and CASH-CS, respectively). Among native Dutch patients, symptoms profiles based on CASH and CASH-CS interviews were very similar. By contrast, among Moroccan immigrant patients, symptom profiles based on CASH and CASH-CS interviews differed substantially, with more mania symptoms (+30%; p < .05) and fewer delusions (-31%; p < .05) reported when using the CASH-CS. These results suggest that the over-diagnosis of schizophrenia in Moroccan immigrants with a first psychosis referral may be related to a tendency to under-detect mood symptoms and over-detect positive psychotic symptoms when a standard diagnostic procedure is used. This bias may be corrected, at least in part, by the use of a culturally sensitive interview instrument such as the CASH- CS.

Predictive validity of a culturally informed diagnosis of schizophrenia: a 30 month follow-up study with first episode psychosis.

UNLABELLED: Previous research has shown discrepancies between a standard diagnostic interview for schizophrenia (CASH) and a culture sensitive version of this instrument (CASH-CS) in Moroccan patients. More specifically we showed that among Moroccan immigrants the CASH-CS resulted in fewer patients with a diagnosis of schizophrenia compared with diagnoses based on the CASH, whereas for Native Dutch patients there was no difference between the CASH and the CASH-CS. The aim of the current study was to compare the predictive validity of a diagnosis of schizophrenia according to the CASH and CASH-CS. METHOD: Thirty months after referral, 26 Moroccan and 26 native Dutch patients with a suspected first psychotic episode were compared with regard to 30-month diagnostic stability, symptom development, psychosocial functioning, medication use and hospitalization using baseline diagnoses based on the two versions of the CASH. RESULTS: Moroccan patients who were diagnosed with schizophrenia using the standard CASH at baseline had a significantly better 30-month prognosis than native Dutch patients with the same CASH diagnosis. Prognosis of schizophrenia according to the CASH-CS was similar for Moroccans and native Dutch patients. Diagnostic stability according to the CASH was high for native Dutch (92%), but low for Moroccan patients (27%), whereas diagnostic stability according to the CASH-CS was high for both groups (85% and 81%, respectively). CONCLUSION: These data raise questions regarding the validity of the standard CASH in Moroccan immigrants in The Netherlands and support the validity of the CASH-CS. As a consequence, there are serious doubts about the validity of previous studies showing an increased incidence of schizophrenia in immigrants using standard diagnostic procedures.

The need for culture sensitive diagnostic procedures: a study among psychotic patients in Morocco.

OBJECTIVE: We examine the procedural validity of a standardized instrument for the diagnosis of psychotic disorders in Morocco. METHOD: Twenty-nine patients from Casablanca, Morocco, with a psychotic or mood disorder were examined using the Comprehensive Assessment of Symptoms and History (CASH) an adapted version using cultural formulation to make the instrument more culturally sensitive (CASH-CS). Chance corrected agreement was calculated between diagnoses based on these two versions of CASH and independent clinical diagnoses according to local psychiatrists. RESULTS: Agreement for traditional CASH versus clinical diagnosis and for CASH versus CASH-CS was low (kappa = -0.19; SD 0.16 and kappa = 0.21; SD 0.16, respectively). De CASH-CS, showed good agreement with clinical diagnosis (kappa = 0.79; SD 0.11). CONCLUSION: Standardized instruments for the assessment of psychosis such as the CASH may be liable to cultural misinterpretations. This may be relevant to the interpretation of the high incidence rates of schizophrenia among immigrants. SIGNIFICANT OUTCOMES: Agreement between a culturally naïve version of a standardized diagnostic instrument for the assessment of psychosis and clinical diagnosis by Moroccan psychiatrists is poor. Adding additional probes and decision rules based on cultural formulation improves agreement with clinical diagnosis significantly. LIMITATIONS: The study was conducted in a small sample. Both versions of CASH were administered by the same interviewer in a single interview session.