Susan Jeffrey

May 26, 2015

TORONTO ― A new survey of psychiatrists in the United States and India has shown differences in how each group weighs symptoms in the diagnosis of common psychiatric disorders, including depression and mania.

The survey showed, for example, that Indian psychiatrists rated somatic symptoms such as pain or fatigue higher in the diagnosis of depression than their American counterparts. Conversely, Indian psychiatrists ranked anger or violent behavior above more subtle symptoms in the diagnosis of acute mania.

The findings underline the fact that cultural differences can affect diagnosis and have implications for studies of global mental health, said lead author Jhilam Biswas, MD, a fellow at the Law and Psychiatry Program of the University of Massachusetts Medical School.

"The impact of this is in global mental health today; there are a lot of parts of the world where there are no psychiatrists," Dr Biswas told a press conference here. "We need to teach community health workers to learn how to triage mental illness, and understanding cultural context is a very important way to teach global mental health."

She pointed out that at least in the United States, there are more international psychiatrists than there are American graduates, "and so picking up cultural biases that might come into play in the diagnostic practices of international psychiatrists in the US or Canada, this research might help to elicit that. As well, in residency training, this is a great way to build up cultural competence."

"I think that data like these make psychiatrists more sensitive to the cultural context of mental illness," Dr Biswas told Medscape Medical News. "It's much more than cultural nuances of diagnosis that these data capture, so that we can be more culturally sensitive when we're in different parts of the world, and have our skills be more universal."

She presented the new findings here at the American Psychiatric Association (APA) 2015 Annual Meeting.

Frequent Debate

A frequent debate in psychiatry involves the extent to which major psychiatric diagnoses are universal across cultures, the authors write.

In this study, the researchers set out to capture differences in diagnostic practices between "two very different parts of the world," Dr Biswas said, Boston, Massachusetts, and Bangalore, India. "Psychiatrists see a huge volume of patients," she said, and "their ability to look at someone and determine diagnoses is a window into how culture affects the presentation of mental illness in a certain country."

Further, understanding how psychiatrists in different parts of the world diagnose mental illness "is a way for all of us to be better international psychiatrists," she added. "Particularly the field of global mental health is certainly advancing and becoming a large part of the psychiatry training programs today, and a big problem in psychiatry is psychiatrists don't often feel comfortable in different cultural contexts, so this might be an evidence-based way of looking at how different psychiatrists diagnose mental illness."

For this study, the researchers surveyed 47 American psychiatrists from three academic centers in Boston and 52 psychiatrists from the National Institute of Mental Health and Neuroscience in Bangalore, India, the largest academic center of psychiatrists and neurologists in India.

Participants ranked symptoms of depression, mania, and psychosis from lists of symptoms taken from the DSM-5 or ICD-10 that both groups were familiar with. They were asked to rank from 1 to 10 symptoms most and least commonly seen among their patients with depression, acute mania, and psychosis in schizophrenia. The participants' responses were then compared.

"What we found was, in general, the top four symptoms for both groups of psychiatrists were similar," Dr Biswas noted, "but what we also found was significant differences in certain types of symptoms."

In depression, for example, US psychiatrists ranked psychological factors such as pessimism and obsessive thoughts higher, whereas Indian psychiatrists ranked somatic complaints higher. Specific somatic pain was particularly divergent between the groups, she said. "The P-value for somatic pain was 0.000000, which means it was actually quite significant."

Table 1. Top Four Symptoms for Depression for Indian vs US Psychiatrists

US Psychiatrists Indian Psychiatrists
Decreased interest in pleasurable activities Easily fatigued
Easily fatigued Decreased interest in pleasurable activities
Pessimistic view of the future Insomnia
Insomnia Specific somatic pain


For acute mania, again the symptoms were similar overall, with symptoms such as grandiosity and decreased need for sleep reported to be common by both groups, and hypersexuality to be least common. "However, in India, what was particularly significant was activation energy ― anger, agitation, violent behavior ― Indian psychiatrists saw that and thought mania, while American psychiatrists didn't," Dr Biswas said. Instead, pressured speech and distractibility were some of the most common symptoms they saw.

Table 2. Top Four Symptoms for Acute Mania: Indian vs US Psychiatrists

US Psychiatrists Indian Psychiatrists
Pressured speech Anger
Decreased need for sleep Decreased need for sleep
Marked distractibility Agitation/violent behavior
Grandiosity or inflated self-esteem Grandiosity or inflated self-esteem


Finally, for psychosis in schizophrenia, both groups ranked in slightly different order the same top four symptoms as well as the least common symptoms, visual hallucinations and peculiar movement disorders. However, Indian psychiatrists found delusions to be much more common, whereas American psychiatrists ranked paranoia higher, she noted.

Table 3. Top Four Symptoms for Psychosis: Indian vs US Psychiatrists

US Psychiatrists Indian Psychiatrists
Paranoia Auditory hallucinations
Lack of insight Delusions
Delusions Lack of insight
Auditory Hallucinations Paranoia


The two groups of psychiatrists were also asked to outline barriers to access to care in their countries.

"In the US and in India, most of the barriers were similar. However, in the US, substance abuse was significantly different," she said. "American psychiatrists found substance abuse to be a big barrier for care, while the Indian psychiatrists did not. The Indian psychiatrists found embarrassing the family as a very big barrier to access to mental health care that American psychiatrists didn't."

The DSM-5 has now incorporated the cultural formulation interview (CFI), with the aim of defining how to ask patients about cultural issues with regard to mental health. During the press conference, Dr Biswas was asked how these new data on the views of different groups of psychiatrists dovetail with that move to incorporate cultural issues among patients.

Dr Jhilam Biswas

"I think that perhaps tools like this study will help us develop better ideas of how mental illness presents and how psychiatrists think about mental illness in a cultural context," she told Medscape Medical News.

"The CFI asks, 'What do you make of your symptoms? What do you call your schizophrenia?' ― questions about what do you name your illness to be and how does family get involved," Dr Biswas said. "I think when we understand the somatic issues ― for example, in the depression data with somatic issues, specific pain is something that we see much more commonly in India or recognize much more commonly in India. If someone says, 'I call it my stomach gurgling,' we might be able to use the information from the CFI and from this type of data to say, okay, now we can think about that as depression.

"If American psychiatrists are doing work abroad, these are ways they can think about using the Cultural Formulation Interview, as well as these data," she added.

Asked to comment on the findings, Jeffrey Borenstein, MD, president and CEO of the Brain and Behavior Research Foundation, in New York City, and chair of the American Psychiatric Association's Council on Communications, called this kind of data "critical when training doctors who will be working on global mental health issues."

"The issue of global mental health and cultural competency is extremely important, and an area of our field that people are looking at more and training is occurring more for this," Dr Borenstein said. "We need to treat the person, not just a bunch of symptoms; that's very important."

"Looking at these issues points out the significance of cultural sensitivity, whether on an international basis or here in the United States, making sure that clinicians are sensitive to cultural issues amongst our population," he told Medscape Medical News.

Although there were a lot of similarities in symptoms cited by psychiatrists, there were some differences, he added, "and some of those differences may have related more to the point in the illness that the patient might be presenting, so it may very well be that some of the differences that occurred really were a part of a larger question of treatment access to care."

This could lead to further research in this area, he noted. "If it turns out that in a particular setting, people aren't getting treatment until the illness is progressed to a further point, that says something about making some adjustments, because early intervention, we know, is the best clinically for patients."

American Psychiatric Association (APA) 2015 Annual Meeting. Abstract P2-2. Presented May 17, 2015.


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