Francisco Collazos

A significant challenge in the culturally sensitive use of psychological and psychiatric instruments for depression is “bias”. Bias means that there is a lack of equivalence: Variation in the score is a result not of variation in the disorder or presence of the symptom in question but rather is due to “cultural factors”. Construct bias is perhaps the most complex of all, and is related to the very manner in which depression is understood. Psychological and psychiatric diagnostic and screening instruments delimit the very “nature” of depression, and fall prey to both false positives and false negatives when assessing individuals from cultures in which the experience and expression of depression is distinct from that found in the West. Equally complex are both method and item bias. In the former, the very method used—for example, a horizontal Likert-like scale—is responded to differentially across cultures, thus resulting in variance that is due not to variations in the presence of symptom but rather the manner of response. Item bias occurs when the item in question is understood in different ways in different cultures. Finally, there is concern about basic issues surround norms, cut-off scores and the like, in as much as the lack of equivalence indicates that results must be interpreted in accordance with population specific norms. Depression diagnostic and screening instruments and their items will be selectively reviewed to demonstrate the presence of bias, and concrete suggestions will be presented to achieve a more culturally sensitive assessment process.

IntroductionThe relationship between immigration and mental health may in part be affected by factors related to social context in general and in relation to specific ethnic groups in specific social contexts. A growing body of research is exploring the impact of neighborhood context on the well-being of immigrants. The specifics, however, have yet to be identified.AimTo analyze the impact of social context on stress and acculturative stress in a hospitalised Latin American immigrant sample.MethodsThe study was part of a larger project concerning stress, coping, and psychosocial well being in Latin American immigrants hospitalised in both internal medicine and obstetrics in a large public hospital in Barcelona (Spain). 290 participants were evaluated with the PSS-10 for general stress, the BISS for acculturative stress and a sociodemographic questionnaire elaborated ad hoc for social context.ResultsNeighborhood socioeconomic level is related to general stress and acculturative stress. A lower socioeconomic level is associated with higher levels of stress and acculturative stress. High levels of ethnic density of Latin American immigrants is moderately associated with lower levels of homesickenss and intercultural contact stress, but are not related with perceived discrimination.ConclusionsSocial context is an important factor that should be considered in the acculturative process of Latin American immigrants and its impact on their mental health status. A low socioeconomic neighborhood level increases levels of stress and acculturative stress, increasing the risk of psychosocial distress.Own group ethnic density would appear to function as a protective factor.

We examined cultural differences in the item characteristic functions of self-reported of symptoms of depression, anxiety, and mania-hypomania in a Latino population taking Computerized Adaptive Tests for Mental Health (CAT-MH) in Spanish versus a non-Latino sample taking the tests in English. We studied differential item functioning (DIF) of the most common adaptively administered symptom items out of a bank of 1,008 items between Latino (n = 1276) and non-Latino (n = 798) subjects. For depression, we identified 4 items with DIF that were good discriminators for non-Latinos but poor discriminators for Latinos. These items were related to cheerfulness, life satisfaction, concentration, and fatigue. The correlation between the original calibration and a Latino-only new calibration after eliminating these items was r = .990. For anxiety, no items with DIF were identified. The correlation between the original and new calibrations was r = .993. For mania-hypomania, we identified 4 items with differential item functioning that were good discriminators for non-Latinos but poor discriminators for Latinos. These items were related to risk-taking, self-assurance, and sexual activity. The correlation between the original and new calibration was r = .962. Once the identified items were removed, the correlation between the original calibration and a Latino-only calibration was r = .96 or greater. These findings reveal that the CAT-MH can be reliably used to measure depression, anxiety, and mania in Latinos taking these tests in Spanish. (PsycINFO Database Record

IntroductionEpidemiological studies reveal higher rates of psychotic disorders among immigrants of ethnic minorities. However, the variation in prevalence of psychosis differs, and the proposed explanations and risk factors vary across the literature.Objectives1) to examine the prevalence of psychotic symptoms in a sample of immigrants and native-born in a primary care setting context2) to explore the effect that certain socio-demographic characteristics have in the difference in prevalence.AimsIt is expected that the presence of psychotic symptoms will be greater for the immigrant population than for the native-born population. Low educational level, a low socio-economic status and the presence of a physical illness will partly explain these differences.Methods3000 patients (1500 immigrants and 1500 native-born outpatients paired in age and gender) were interviewed in a primary care setting. They completed the Mini International Neuropsychiatric Interview, including the psychotic disorders sections, and a questionnaire that probed demographic characteristics and physical health status.ResultsImmigrants showed significantly higher rates of psychotic symptoms than native-born patients in both sections of diagnosis: life-span psychotic symptoms only (9.8% in immigrants and 5.3% in native-born) and life span with current psychotic symptoms (7% of the immigrants and 4.8% of the native-born). Immigrants also showed a lower education level, and a lower socio-economic status. When controlling for these factors, a relationship between these factors and the symptoms was found.ConclusionsFindings are discussed in the context of culture and etiology of psychotic symptoms, and suggestions with regard to future research are made.

BACKGROUND AND AIMS:The focus of this paper is on the improvement of substance use disorder (SUD) screening and measurement. Using a multidimensional item response theory model, the bifactor model, we provide a psychometric harmonization between SUD, depression, anxiety, trauma, social isolation, functional impairment, and risk-taking behavior symptom domains providing a more balanced view of SUD. The aims are to (1) develop the item-bank, (2) calibrate the item-bank using a bifactor model that includes a primary dimension and symptom-specific subdomains, (3) administer using computerized adaptive testing (CAT), and (4) validate the CAT-SUD in Spanish and English in the U.S. and Spain.DESIGN:Item bank construction, item calibration phase, CAT-SUD validation phase.SETTING:Primary care, community clinics, emergency departments and patient-to-patient referrals in Spain (Barcelona and Madrid) and the US (Boston and Los Angeles).PARTICIPANTS/CASES:Calibration phase: the CAT-SUD was developed via simulation from complete item responses in 513 participants. Validation phase: 297 participants received the Composite International Diagnostic Interview (CIDI) and the CAT-SUD.MEASUREMENTS:252 items from 5 subdomains: (1) SUD, (2) psychological disorders, (3) risky behavior, (4) functional impairment and (5) social support. CAT-SUD scale scores and CIDI SUD diagnosis.FINDINGS:Calibration: The bifactor model provided excellent fit to the multidimensional item bank. 168 items had high loadings (>0.4 with the majority >0.6) on the primary SUD dimension. Using an average of 11 items (4-26), which represents a 94% reduction in respondent burden (average administration time of approximately 2 minutes), we found a correlation of 0.91 with the 168-item scale (precision of 5 points on a 100-point scale). Validation: Strong agreement was found between the primary CAT-SUD dimension estimate and the results of a structured clinical interview. There was a 20-fold increase in the likelihood of a CIDI SUD diagnosis across the range of the CAT-SUD (AUC=0.85).CONCLUSIONS:We have developed a new approach for the screening and measurement of SUD and related severity based on multidimensional item response theory. The bifactor model harmonized information from mental health, trauma, social support and traditional SUD items to provide a more complete characterization of SUD. The CAT-SUD is highly predictive of a current SUD diagnosis based on a structured clinical interview, and may be predictive of the development of SUD in the future.

As healthcare systems are challenged to respond to the linguistic and cultural diversity that accompanies migrations, a common response is the deployment of the figure of the ‘intercultural mediator’ (ICM). This chapter will explore some of the key issues related to intercultural mediation that complicate the ICM being an effective component of interculturally competent mental health care. We provide a background of the rationale for the existence of the ICM and outline some of the serious factors, both conceptual and practical, which complicate matters, and explore the specific role possibilities for effective functioning in mental health care settings.

Aims: The relationship between immigration and drug abuse and its treatment is complex and poorly understood. The objective of this study is to gain insight into patterns of drug use and service access and how they are influenced by social factors and the migratory process in a population of foreign born drug users in Barcelona, Spain. Methods: An interview protocol was developed for the study which examined drug use patterns, social and health factors, and treatment, and was administered to 118 foreign born users in harm reduction centers. 92% were male and 8% were female. 42% were from Eastern Europe, 35% were from the Magreb, 14% from the European Community, 6% from Subsaharan Africa and 3% from Latin America. Results: With migration opium use decreased whereas cocaine, heroin, and speedball increased, which also constitute the primary drug used by this sample. Social support was correlated with greater consumption of heroin, cocaine, and alcohol, whereas lower social stress was predictive of higher cannabis use. Hard drug use was predicted by illegal status and a lack of stable housing. Acculturation and acclturative stress were not found to be related to substance use. Treatment was positively evaluated, with no perception of lower quality of care. Discussion: Drug use patterns shift with the migratory process, and, it would appear, adapt to the dominant local ones. The unexpecting findings regarding social factors and acculturation and acculturative stress may indicate differences in the Spanish drug use context, and as such warrant further research.

The construct “Cultural competence”, or some variation thereof, has unfortunately been abused to the point that it really has no clear definition and, indeed, can signify rather contrasting notions (Kirmayer 2012; Kleinman and Benson 2006; Qureshi and Eiroa-Orosa 2012; Williams 2006). Given that the point of this chapter is to apply the concept to trauma work with immigrants with the goal of improving service provision, it will simply focus on this very point and in the process explicate a model of cultural competence that it is hoped will be useful just as it is in accord with research and with overall approaches to effective clinical work with diverse patients.

Body Uaccompanied migrant youth represent an at-risk population given the complexity of negotiating adolescence in a new culture, isolated from family and friends, without a secure base and subject to discrimination. In addition, many unaccompanied migrant youth have been subject to considerable trauma prior to, during, and post migration. In Spain, as in many countries, the residential, care, and mental health services are not adapted to the specific and complex needs of this population, and to that end complex not only are the youth not well served but providers are increasingly frustrated. The figure of the community health agent has been widely recognized as one that can function as an effective bridge between systems/institutions and marginalized and vulnerable populations. In this presentation we will describe an ongoing project that trains unaccompanied migrant youth who show promise in their cultural adaptation in the areas of cultural competence, mental health care and subs...

Entre las multiples necesidades de los refugiados que llegan en Europa, se debe prestar una especial atencion a la proteccion de su salud mental y su bienestar psicosocial. La revision de la literatura presenta una heterogeneidad en las tasas de trastornos mentales debida, al menos en parte, a las caracteristicas de los grupos estudiados, el contexto y la situacion en el pais de acogida, y la calidad metodologica de los estudios, particularmente con los metodos de muestreo. Mas alla del debate acerca de la relevancia intercultural de los diagnosticos de enfermedades mentales, los problemas de salud mental relacionados con la inmigracion forzada varian: reacciones normales a eventos "a-normales"; exacerbaciones de trastornos de salud mental pre-existentes; problemas impulsados por la violencia y el desplazamiento relacionados con conflictos, problemas relacionados con la adaptacion al pais de acogida, etc. Los factores que influyen en el estado de salud mental y el bienesta...

Changes in sulcal cerebrospinal fluid (CSF) volume have been related to the neurodegeneration hypothesis in schizophrenia. Fifty-three (24 neuroleptic-naive) schizophrenics and a control group (n=26) were studied with MRI to assess regional sulcal CSF values relative to the total volume of brain lobes (prefrontal, orbital, temporal, parietal, and occipital). Segmentation of brain structures was performed using an automatic Talairach-based method. Relative CSF volumes were adjusted for age by means of linear regression from normal subjects; the corrected values were used to assess their relationship with illness duration and age of onset (AOS). The volume of sulcal CSF on prefrontal and temporal lobes (bilateral) was significantly greater in schizophrenic patients and showed a significant positive correlation with illness duration not found in the other regions studied. No significant association between CSF volumes and AOS was found in any region. Our findings support the existence of a degenerative process in schizophrenia located in prefrontal and temporal areas.

El incremento en la inmigración observado en España en los últimos años ha abierto un debate sobre la relación entre el proceso migratorio y el desarrollo de ciertos problemas psicopatológicos. Estudios realizados en Europa y Estados Unidos han mostrado ...

Supplemental material, TPS916697 Supplemental Material2 for Treating immigrant patients in psychiatric emergency rooms by Francisco Collazos, Ángeles Malagón-Amor, Irene Falgas-Bague, Adil Qureshi, Jose Maria Gines, Maria del Mar Ramos, Samantha McPeck, Isra Hussain, Ye Wang and Margarita Alegría in Transcultural Psychiatry

We examine whether patient variables (geographic origin, gender, Spanish language proficiency) and subjective clinician aspects in emergency department psychiatric encounters (diagnostic certainty, clinician’s comfort level with patient) are associated with diagnosis and the use of coercive measures. Using a descriptive cross-sectional design, we recorded 467 visits (400 foreign-born and 67 native-born patients) in hospital psychiatry emergency rooms (ERs) in Barcelona between 2007 and 2015. We first assessed the association of patient variables and subjective clinician aspects of psychiatric encounters with service use outcomes and with mental illness diagnosis. Fitted logistic models predicted the likelihood of service use outcomes and estimated the propensity of receiving each diagnosis. The null model evaluated the role of patient’s geographical origin, while the full model evaluated the additional roles of patient’s gender and language, the clinician’s assessment of the influen...

In the study of mental health and migration, an increasing number of researchers have shifted the focus away from the concept of acculturation towards the stress present in the migratory experience. The bulk of research on acculturative stress has been carried out in the United States, and thus the definition and measurement of the construct has been predicated on that cultural and demographic context, which is of dubious applicability in Europe in general, and Spain in particular. Further, some scales have focused on international students, which down-played the importance of the migratory process, because it deals with a special subset of people who are not formally immigrating. The Barcelona Immigration Stress Scale was developed to measure acculturative stress appropriate to immigrants in Spain, using expert and focus group review and has 42 items. The scale shows acceptable internal validity, and, consistent with other scales, suggests that immigration stress is a complex const...

Despite the numerous advances in psychiatry such as neuroimaging techniques, structured interviews, and comprehensive diagnostic protocols, all too frequently a patient's symptomatology does not fit neatly into a recognized diagnostic category. Given the increasing popularity of treatment guidelines, purportedly predicated on hard science, clinical uncertainty becomes increasingly problematic, precisely because the guidelines are aimed at specific and discrete psychopathological categories. On the one hand, clinical reality is complex, contradictory, and most certainly contested. On the other, medical training and professional demands require that the psychiatrist demonstrate certainty, be it to patients, colleagues, health insurance providers, other third parties, and perhaps most controversially, to themselves. Faced with clinical uncertainty, the clinician may find herself or himself in a difficult situation: recognition of the uncertainty is regarded as an indication of poor professional performance, whereas assertion of a diagnosis or plan of treatment runs a very real possibility of contravening the beneficence principle. Clinical uncertainty is all the more pronounced in the face of certain mental disorders, cultural, age, and gender difference, and training model. This paper will examine some of the key factors related to clinical uncertainty and how it relates to clinical practice. It will be suggested that clinical uncertainty itself represents an important source of diagnostic information and rather than be ignored should in fact be incorporated into the diagnostic and treatment process.

A significant challenge in the culturally sensitive use of psychological and psychiatric instruments for depression is “bias”. Bias means that there is a lack of equivalence: Variation in the score is a result not of variation in the disorder or presence of the symptom in question but rather is due to “cultural factors”. Construct bias is perhaps the most complex of all, and is related to the very manner in which depression is understood. Psychological and psychiatric diagnostic and screening instruments delimit the very “nature” of depression, and fall prey to both false positives and false negatives when assessing individuals from cultures in which the experience and expression of depression is distinct from that found in the West. Equally complex are both method and item bias. In the former, the very method used—for example, a horizontal Likert-like scale—is responded to differentially across cultures, thus resulting in variance that is due not to variations in the presence of sy...

La conferencia internacional «Refugees on the move: thinking beyong the Euro-Mediterranean crisis» (21 y 22 de abril 2016) que inspira esta publicación, fue organizada gracias a la subvención de la Generalitat de Catalunya, AGAUR, a través el proyecto GRC-SGR 2014 (1524).En el marco del CER-M (UAB-UB), hemos organizado la conferencia internacional «Refugees on the move: thinking beyong the Euro-Mediterranean crisis» celebrada el 21 y 22 de abril 2016 en el CCCB y Espai Contrabandos. Esta conferencia tuvo como objetivo crear un espacio de debate y reflexión en torno a las implicaciones teóricas, político-legales y sociales que estos desplazamientos están conllevando. En el evento participaron académicos de ámbito nacional e internacional, así como personas expertas y profesionales que trabajan sobre el terreno. Fruto de estas jornadas, y a partir de las aportaciones de sus participantes, el equipo del CER-M (UAB-UB) presentamos este monográfico bilingüe.The CER-M (UAB-UB) organised t...

As healthcare systems are challenged to respond to the linguistic and cultural diversity that accompanies migrations, a common response is the deployment of the figure of the ‘intercultural mediator’ (ICM). This chapter will explore some of the key issues related to intercultural mediation that complicate the ICM being an effective component of interculturally competent mental health care. We provide a background of the rationale for the existence of the ICM and outline some of the serious factors, both conceptual and practical, which complicate matters, and explore the specific role possibilities for effective functioning in mental health care settings.

The continuous international migration flow invites us to reinvent ourselves to create inclusive societies at intercultural level. Coexistence, as a model based on the mutual integration of locals and migrants, is still a challenge to face in Europe and Spain. This study aims to identify which mental health and resilience variables influence school integration used as a proxy for psychosocial well-being by comparing a sample of migrant and local adolescents. Through a quantitative methodology, school factors, disruptive behaviors, and resilience were measured in 132 students aged between 12 and 18 years old. The results reveal that although mental health scores are similar in both groups, mental health and contextual resilience are more critical for the migrant adolescent population than for the local one. Clearly identifying the relationships between school related factors and mental health offers the possibility of designing effective interventions within the educational context.

The increasing presence of culturally different clients in European health services constitutes an important challenge for the effective delivery of care. Cultural competence has been proposed as a general approach for improving services, which requires changes at both institutional and clinical levels. The majority of cultural competence models have been developed in the United States and as such may require adaptation for use i nE urope. The key constructs of culture, ethnicity and race underlie important philosophical perspectives in cultural competency models. How these constructs, particularly race, are understood to relate to health and healthcare is of considerable importance in both the development of the competency models and their application and acceptability, which are not always the same, in a given context. Clinical cultural competence consists of specific knowledge, skills, and attitudes that function together to provide an individualised, culturally sensitive and app...

a progressive tendency to rise until reaching 25% in very few years. The significant increase in immigration which has taken place in Spain in the last few years poses a large number of challenges among which are those related to mental health assistance for these people. In this sense, mental health professionals wonder if there is any relationship between the migratory process and the subsequent development of psychopathology (Achotegui, 2002; Collazos, Qureshi & Casas, 2005; Gracia

Latino/as in the United States and Spain make up a disproportionate percentage of cases of HIV infection, and often are diagnosed later than their non-Latino/a counterparts. Understanding the factors that affect HIV testing in different contexts is critical to best promote HIV testing, which is considered essential to both prevention and early treatment. This study explored differences in HIV testing rates among Latino/a participants in an international study designed to examine behavioral health screening for Latino/a populations. We collected data on testing rates and results from 407 Latino/as—both first generation immigrants and those of Latino/a descent—in the United States (Boston) and Spain (Madrid and Barcelona), through interviews conducted in community clinics and agencies. Using multivariate logit models, we evaluated predictors of screening and positive testing, adjusting for sex, age, and clinic type. HIV testing rates were highest in Boston, followed by Barcelona and Madrid (82%, 69%, and 59%, respectively, p < .0001). In multivariate regression models, Barcelona and Madrid patients were significantly less likely to have received testing than Boston patients. Significant positive predictors of HIV testing were: education level higher than high school, HIV concerns, infrequent condom use, other risk behaviors, reports of discrimination, and higher benzodiazepine consumption. Significant differences in HIV testing found in this study help to illuminate best practices for engaging patients in testing across sites. Los latino/as representan, tanto en Estados Unidos como en España, un porcentaje desproporcionado de los casos de infección por el VIH y, a menudo son diagnosticados más tarde que sus homólogos no latino/as. Conocer los factores que influyen en la realización de la prueba del VIH en diferentes contextos resulta fundamental para la promoción de dicha prueba, lo que se considera esencial tanto para la prevención como para el tratamiento precoz. Este estudio internacional explora las diferencias en las tasas de realización de la prueba de VIH entre participantes latino/as y que fue diseñada para examinar el estado de salud mental de los imigrantes latino/as. Para ello, se han recopilado datos sobre las pruebas del VIH y sus resultados en 407 latino/as - tanto inmigrantes como de ascendencia latina- en los Estados Unidos (Boston) y España (Madrid y Barcelona). La información fue recogida en entrevistas realizadas en clínicas y agencias comunitarias. Se evaluaron los factores que predicen hacerse la prueba de VIH y de tener resultados positivos en la misma, ajustando por género, edad y el sitio de reclutamiento del paciente, y empleando para ello un modelo de regresión logística multivariado. La tasa más alta de realización de la prueba de VIH fue la de la población de Boston, seguida por Barcelona y Madrid (82%, 69%, y 59%, respectivamente, p < .0001). Según los modelos de regresión multivariada, la probabilidad de que los pacientes de Barcelona y Madrid se hicieran la prueba fue significativamente menor que la de Boston. Entre los predictores positivos para realizarse la prueba estaban un grado de escolarización superior a la secundaria, el grado de preocupación por el VIH, el uso infrecuente del condón, el informar experiencias de discriminación y el uso elevado de benzodiacepinas. Las diferencias significativas entre las tasas de realización de la prueba del VIH entre las tres ciudades sugieren la necesidad de gestionar mejores prácticas para atraer a los pacientes hacia la realización temprana de la prueba.

We examined cultural differences in the item characteristic functions of self-reported of symptoms of depression, anxiety, and mania-hypomania in a Latino population taking Computerized Adaptive Tests for Mental Health (CAT-MH) in Spanish versus a non-Latino sample taking the tests in English. We studied differential item functioning (DIF) of the most common adaptively administered symptom items out of a bank of 1,008 items between Latino (n = 1276) and non-Latino (n = 798) subjects. For depression, we identified 4 items with DIF that were good discriminators for non-Latinos but poor discriminators for Latinos. These items were related to cheerfulness, life satisfaction, concentration, and fatigue. The correlation between the original calibration and a Latino-only new calibration after eliminating these items was r = .990. For anxiety, no items with DIF were identified. The correlation between the original and new calibrations was r = .993. For mania-hypomania, we identified 4 items...

Early detection and intervention in primary care is integral to behavioral health. Valid, practical screening assessments are scarce, particularly for non-English speaking populations. We address this need by evaluating the psychometric properties of the Spanish version of the AC-OK Screen for Co-occurring Disorders for first and second generation immigrant Latinos in Massachusetts, USA, and Madrid and Barcelona, Spain. 567 Latino participants were recruited in waiting areas of clinics or by referral from Primary Care, Mental Health, Substance Use, and HIV Treatment Clinics, as well as Community Agencies. We use confirmatory factor analyses to evaluate the factor structure, correlation analysis to examine concurrent and discriminant validity, and receiver operating curves (ROC) to determine the ability of the AC-OK to approximate a composite of established instruments designed to measure depression, generalized anxiety, post-traumatic stress disorder symptoms, alcohol, and drugs (including benzodiazepines) as external criteria. The original two factor structure was replicated in samples of Latino respondents in the US and Spain. Correlations with other measures followed the expected pattern. In both the US and Spain, ROC analyses suggested that the AC-OK scale was an adequate approximation to other specific measures of mental health (ROC=0.90) and substance abuse problems (ROC=0.83). The Spanish version of the AC-OK Screen has good to excellent psychometric properties in both its subscales. These findings are robust across sites, gender, and type of clinic. We recommend its use for clinical research and for routine screening at treatment centers.

The use of legal and illegal substances by medical students is a phenomenon that is only partially known. The aim of this paper was to review the literature published internationally in the last 25 years about the use of legal and illegal substances by medical students. A systematic search was made of MEDLINE and LILACS. One hundred and six manuscripts were evaluated, which included a population of 88,413 medical students. We validated 74,001 questionnaires, which represented 83.7% of responses. The methodology and the rigor of its application are not the same in all the publications. There are many regional variations, most studies being made in America and Europe. With the exception of alcohol in some areas of the Western world, medical students use substances less than university students in general and the general population. The substances used are mainly alcohol (24%), tobacco (17.2%), and cannabis (11.8%). The use of hypnotic and sedative drugs also is common (9.9%). The rate...