BJP -- eLetters for Steel et al., 194 (4) 326-333

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Zachary Steel, Derrick Silove, Nguyen Mong Giao, Thuy Thi Bich Phan, Tien Chey, Anna Whelan, Adrian Bauman, and Richard A. Bryant
International and indigenous diagnoses of mental disorder among Vietnamese living in Vietnam and Australia
The British Journal of Psychiatry 2009; 194: 326-333 [Abstract] [Full text] [PDF]

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The CIDI in developing countries: Sing Lee, Adley Tsang, Wanjun Guo (17 April 2009)

Culturally valid assessment and psychiatric epidemiology: Zachary Steel, Derrick Silove (26 May 2009)

The CIDI in developing countries 17 April 2009

Sing Lee,
Reader
Department of Psychiatry, The Chinese University of Hong Kong,
Adley Tsang, Wanjun Guo
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Re: The CIDI in developing countries

singlee{at}cuhk.edu.hk Sing Lee, et al.

Steel and coworkers (Journal, 2009, 194, 326-333) should be commended for using an innovative design to show that the CIDI 2.0 missed a large proportion of diagnoses that could instead be captured by an indigenously based Phan Vietnamese Psychiatric Scale (PVPS) among Vietnamese. Interpretations of the study should also consider the following.
1. Comparison between the self-report PVPS and CIDI included two other methodological issues that have little to do with whether the PVPS was indigenously devised. First, face-to-face structured interviews have long been shown to bias against Asians in the elicitation of psychiatric symptoms. By contrast, Asians typically scored comparably high as Westerners on many self-report scales such as the GHQ (1). Second, unlike the 53-item PVPS, the CIDI contains multiple skip-outs from further symptom questioning unless mandatory DSM-IV core symptoms are endorsed. This renders the hierarchically configured CIDI much more prone to false negatives (2).
2. The majority of diagnoses captured by the PVPS (72%) were in the somatization category but somatoform disorders were not assessed in the CIDI (because of difficulty in operationalizing the concept of ¨medically unexplained symptoms〃). Recent versions of the CIDI (3.0 and 3.1) contain a section on chronic pains and other physical illnesses, which have been shown to be common and highly comorbid with mental disorders in both developed and developing countries (3).
3. The CIDI surely requires improvement regarding downward bias in prevalence estimates in Asian countries. China has used several versions of it (1.0 to 3.1). By adhering strictly to linguistic accuracy, the earlier versions generated unbelievably low prevalence of depression. Prevalence estimates continue to rise with successive versions and the latest survey using CIDI 3.1, by taking careful account of contextual equivalence of stem questions, interviewer training and quality control in the field, has found a prevalence of depression little different from those of many Western countries. The Chinese CIDI has also provided highly consistent epidemiological data regarding specific disorder distributions, lifetime rates, psychosocial associations, physical/mental comorbidity, treatment-seeking and the opportunity for large-sample cross-national analysis (4). Enhancement of the CIDI may be both challenging and worth re -considering in Vietnam.
1. Cheung FM. Psychological symptoms among Chinese in urban Hong Kong. Soc Sci Med 1982; 16:1339-44.
2. Lam CY, Pepper CM, Ryabchenko KA. Case identification of mood disorders in Asian American and Caucasian American college students. Psy Quarter 2004; 75:361-73.
3. Scott KM, Von Korff M, Alonso J, Angermeyer MC, Bromet E, Fayyard J, et al. Mental-physical co-morbidity and its relationship with disability: results from the World Mental Health Surveys. Psychol Med 2009; 39:33-43.
4. Lee S, Tsang A, Von Korff M, de Graaf R, Benjet C, Haro JM, et al. Association of headache with childhood adversity and mental disorder: cross-national study. Br J Psych 2009; 194:111-6.

Culturally valid assessment and psychiatric epidemiology 26 May 2009

Zachary Steel,
Senior Lecturer
University of New South Wales,
Derrick Silove
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Re: Culturally valid assessment and psychiatric epidemiology

z.steel{at}unsw.edu.au Zachary Steel, et al.

In summary, our report identified lower diagnostic concordance between the CIDI 2.0 and the indigenously derived Phan Vietnamese Psychiatric Rating Scale (PVPS) amongst Vietnamese in the Mekong Delta region compared to Vietnamese in Australia. Whereas rates of mental disorder identified by the PVPS were stable across countries, CIDI identified mental disorder was three times lower in the Mekong Delta. Of particular importance was that the CIDI failed to detect 75% of equally disabled PVPS cases in Vietnam.
Sing Lee and colleagues raise important questions that need to be resolved in order to make sense of the findings of international psychiatric epidemiology. We address some of their concerns in relation to our method. Although technically the PVPS is a questionnaire, it was administered in interview format as is common in the transcultural setting. Moreover, there is some evidence that amongst Vietnamese, there is a tendency to use a restricted range in reporting symptom severity on questionnaires [1], a factor that would yield conservative rates . Dr Lee and colleagues suggest that the skip rules of the CIDI may lower prevalence rates. We concur that the pre-eminence given to psychological rather than somatic stem symptoms in the hierarchical structure of the CIDI [2] might limit positive endorsements in non-western countries. However, if this effect was present it differentially impacted on the Mekong Delta sample, underscoring the importance of culture and 憌esternization� as a influence on psychiatric assessment. We look forward to the publication of the results from the Chinese trials of the CIDI 3.1 which have re-formulated the stem questions to be more compatible with somatic idioms of distress.
We do note however, that removing PVPS cases that only reached threshold on the somatisation scale would have reduced our prevalence rates by 2.8% in Vietnam and 3.0% in Australia. Hence, the PVPS would still have identified a substantial number of cases not yielded by the CIDI. We note too that the western derived measure of neurasthenia recorded low rates in all samples suggesting that somatic measures need to be culture-specific.
In summary, there does not seem to be any major disagreement here. Whether we produce indigenous measures ab initio, as we have done, or modify existing measures as undertaken by Sing Lee and colleagues with the CIDI 3.1, the inference we draw remains the same: in order to detect the full range of disabling mental disorders across cultures, we need to have culturally appropriate measurement. We can抰 simply apply the same measure with the same wording of items in the same format to all cultures and expect that we can compare the results. The cost of applying either adapted or culturally-developed measures, however, is that it confounds the process of making direct international comparisons of prevalence rates and mental health need. Hence, the real challenge facing world psychiatry is how to combine the strengths of psychiatric epidemiology [3] with improvements in culturally valid assessment [4, 5]. Showing consistent patterns of comorbidity and risk factor profiles across countries can only partially address this issue. Zachary Steel, Derrick Silove Declaration of interest: none
1. Beiser M, Fleming JA. Measuring psychiatric disorder among Southeast Asian refugees. Psychological Medicine. 1986;16(3):627-639.
2. Shen YC, Zhang MY, Huang YQ, He YL, Liu ZR, Cheng H, Tsang A, Lee S, Kessler RC. Twelve-month prevalence, severity, and unmet need for treatment of mental disorders in metropolitan China. Psychological Medicine. Feb 2006;36(2):257-267.
3. Kessler RC, Angermeyer M, Anthony JC, de Graaf R, Demyttenaere K, Gasquet I, de Girolamo G, Gluzman S, Gureje O, Haro JM, Kawakami N, Karam A, Levinson D, Mora MEM, Browne MAO, Posada-Villa J, Stein DJ, Tsang CHA, Aguilar-Gaxiola S, Alonso J, Lee S, Heeringa S, Pennell BE, Berglund P, Gruber MJ, Petkhova M, Chatterji S, Ustun TB. Lifetime prevalence and age- of-onset distributions of mental disorders in the World Health Organization's World Mental Health Survey Initiative. World Psychiatry. Oct 2007;6(3):168-176.
4. Silove D, Bateman C, Brooks R, Zulmira FCA, Steel Z, Rodger J, Soosay I, Fox G, Patel V, A B. Estimating clinically relevant mental disorders in a rural and urban setting in post-conflict Timor Lest. Archives of General Psychiatry. 2008;65(10):1205-1212.
5. Patel V, Simbine AP, Soares IC, Weiss HA, Wheeler E, Patel V, Simbine APF, Soares IC, Weiss HA, Wheeler E. Prevalence of severe mental and neurological disorders in Mozambique: a population-based survey. Lancet. Sep 22 2007;370(9592):1055-1060.