Culture and assessment of manic symptoms

Cultural background may influence the perception of psychiatricsymptoms. We examined the effects of cultural biases on theidentification of manic symptoms using the Young Mania RatingScale. Two video interviews, each with an American person withmania, were shown to psychiatrists from three countries (US,UK and India). Total scores on the scale differed significantly between the US and UK (P<0.001) and between India and UK (P<0.001) rater groups. Overall, differences between Indiaand US rater groups were less marked (P=0.28). These differencessuggest that cultural biases influence the interpretation ofmanic symptoms.

INTRODUCTION

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INTRODUCTION

It has previously been noted that ‘behaviour pertinentto psychiatry is relative to culture, and cultural differencesmust enter to some extent into the definitions and perceptionsof psychiatric disorders’ (Savage et al, 1965). TheAmish Study of affective disorders (Egeland et al, 1983) investigatedthe impact of the masking or modification of psychiatric symptoms by social definition and cultural overlay. It was reportedthat the correct diagnosis was hindered by the interpretationof symptoms of grandiosity, excessive activity, form of thought,thought content and paranoid features. Other studies have alsoreported that cultural background affects the presentationand diagnosis of bipolar disorder (Strakowski et al, 1996;Kirov & Murray, 1999).

Psychiatric rating instruments are often used in clinical andresearch settings to quantify objectively the presence andseverity of the specific, individual symptoms and behaviouralaspects of the disorder being evaluated. The psychometric propertiesof these rating instruments are typically established in circumscribedpatient populations drawn from the geographical locality ofthe scale developers. The adaptation of the scale to related psychiatric disorders or to populations from other cultures,using different languages and contexts, may affect the validityof the instrument. We used the Young Mania Rating Scale (YMRS;Young et al, 1978) to explore inter-cultural biases between English-speaking raters from three countries (UK, USA and India)when evaluating acute mania in two American patients.

METHOD

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METHOD

Two videotaped interviews, each with an American with maniaand clearly in an abnormal mental state, were shown to a totalof 126 trained English-speaking clinician raters from threedifferent countries: 20 from the UK, 24 from India and 82 fromthe US, as part of a rater qualification programme for conductingglobal clinical trials. Although there were training and educationaldifferences as well as the obvious geographical differences, all raters had previous clinical experience with bipolar disorderand the YMRS. Raters were asked to observe and independentlyscore each of the YMRS items for both patients. Raters weretold that their scores would be compared with those of otherraters for interrater reliability. All participants gave theirfully informed consent to participate in this study, following explanation of the protocol.

The YMRS includes 11 items rated with increasing severity from0 (absent symptoms) to 4 or 8, depending on the item. The firstYMRS video interview examined a woman with bipolar disorder(patient A) who was over-enthusiastic about a new job in adepartment store, advising women on fashion accessories. Thesecond interview examined a man (patient B) who talked quickly,expressed grandiose ideas, had difficulty sitting still throughthe interview, was socially inappropriate at times and seemedunconcerned about his behaviour.

Analysis of variance (ANOVA) models were used in the statisticalanalysis. For each individual patient, each item on the YMRS,as well as the mean total score, was analysed separately ina one-way ANOVA with country (US, UK or India) as the factorin the model. For the overall analysis, a two-way ANOVA withcountry and patient as factors was used. F-test scores were first reported to test for differences between the three countries,and pairwise contrasts (of each vignette across different countries)were used to test for differences between individual pairsof countries. Results are presented as mean (s.e.). Statisticalsignificance is defined as P<0.05.

RESULTS

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RESULTS

Figure 1 shows the distribution of mean total YMRS scores foreach country for both participants. For patient A, mean totalscores were: India 30.5 (0.78); UK 20.6 (0.58); US 31.6 (0.33).Total scores for patient B were: India 40.8 (0.68); UK 27.1 (0.97); US 38.6 (0.32). Total YMRS scores differed significantlyon both interviews between the US and UK raters (P<0.001),India and the UK (P<0.001), and on one interview betweenthe US and Indian raters groups (P=0.004). Overall analysisrevealed that there was a significant difference in mean totalYMRS scores across countries (P<0.001), and comparison ofindividual countries revealed differences between India v.UK (P<0.001) and UK v. US (P<0.001), but not India v.US (P=0.28).

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Fig. 1 Total Young Mania Rating Scale (YMRS) scores by country: (a) patient A; (b) patient B.

Individual item analysis revealed significant differences betweencountries on 10 of the 11 YMRS items on each of the two interviews,the direction of these differences reflecting overall meantotal score for each individual country. The most profounddifferences were noted for mood elevation (item 1; P<0.001),irritability (item 5; P<0.001), thought content (item 8;P<0.001), and disruptive–aggressive behaviour (item9; P<0.001).

DISCUSSION

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DISCUSSION

This YMRS was developed with the participation of people withmania from New York State. Hitherto the impact of differingcultures on the assessment of manic symptoms using this ratinginstrument has not been quantified. Our data reveal that English-speakingpsychiatrists from three different countries showed a markeddisparity in detecting and rating manic symptoms, reflecting the distinctive clinical perspectives of the raters from eachcountry. Indian raters saw the manic behaviour of the Americanpatients as significantly more ill and inappropriate than didAmerican raters. Conversely, the British raters generally ratedthese same American patients with mania significantly lower compared with the American raters.

Although only two cases were analysed, the differences in scoresbetween the three countries suggest that intercultural biasesaffect the interpretation of manic symptoms. We cannot excludethe possibility that other factors, in addition to culturalbackground, may also have influenced these results. Age, gender,psychiatric training, years of experience, etc., may have actedas confounding variables, in addition to other common evaluation errors (e.g. the halo effect or logistical errors). However,unless all these factors are controlled for, similar variabilityis likely to be present when rating patients in routine clinicalpractice or in research studies.

Although preliminary, these data have potentially importantimplications not only for diagnostic and epidemiological studies,but also for the design of clinical drug trials in which ratinginstruments are used to assess baseline symptom severity andimprovement. Large epidemiological studies such as ÆSOP(Aetiology of Schizophrenia and Other Psychoses) have reported the incidence of bipolar disorder in three UK cities (Lloyd et al, 2005). In the ÆSOP study, cases were defined by a group of cliniciansfrom multicultural backgrounds, and an assumption was madethat manic symptoms are universal phenomena and equally detectable.Our data suggest that the cultural background of the clinicianmay have a direct influence on the diagnosis of bipolar disorder.

With regard to multicentre clinical drug trials, these datasuggest that potential participants in studies of people withmania are more likely to be enrolled if assessed by a psychiatristfrom India or the US rather than a psychiatrist from the UK,if a YMRS minimum score is stipulated as an entry criterion.Conversely, participants rated by a psychiatrist from Indiaor the US are less likely to satisfy conventional criteriafor improvement (i.e. an improvement of 50% or more on YMRSscore) than those rated by a psychiatrist from the UK. Trialdesigners recruiting sites and raters from multiple countriesneed to consider the potential confounding impact of culturalbias when evaluating data generated from such studies.

These findings should prompt further discussion, and other largestudies using patients in real-life clinical settings and cliniciansfrom other cultural backgrounds are needed.

REFERENCES

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