Indian contribution to the cultural formulation interview and the DSM-5: Missing details from the position paper.

Sir,

We recognize the reasonable concerns about the mismatch of global aspirations and the parochial scope of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Nevertheless, we regret to point out that the position paper of the Indian Psychiatric Society[1] omits acknowledgment of substantial relevant contributions to the cultural sensitivity of the DSM-5 from India and other sites outside the DSM's home base in North America.

The Cultural Formulation Interview (CFI), noted in the paper, has been developed by an international consortium of mental health-care providers, the DSM-5 cultural issues subgroup of the gender and culture study group. The cultural formulation approach and the CFI for clinical assessment share common interests and benefit from experience with Explanatory Model Interview Catalogue (EMIC) interviews first used in India for research in cultural psychiatry and cultural epidemiology by Weiss.[2] This experience has contributed to the development of the CFI for comprehensive assessment of cultural dimensions of patients’ problems.

A multi-center validation study of the CFI for DSM-5 involved international collaboration of investigators at 13 field sites in 6 countries, not only the United States but also India, Peru, The Netherlands, Canada and Kenya. Two sites in India participated, one in Pune at KEM Hospital and the other in New Delhi at PGIMER - Dr. Ram Manohar Lohia Hospital. Each department prepared translations in Marathi and Hindi respectively. Clinician interviewers were trained using a training video prepared by Dr. Jadhav for all sites, and administration of the CFI was followed by debriefing of clinicians and patients to assess its clinical utility, feasibility and acceptability.

The principal investigators participated in regular weekly or biweekly conference calls over 18 months with cross-site collaborators, engaging in a process of consensual validation of the form and content of the CFI. Broad participation in conduct of the trials by the departments of psychiatry at both centers resulted in the largest recruitment of study subjects of any country apart from the United States. A background review of cultural concepts of distress, which includes a section on Dhat syndrome and consideration of cultural conditions associated with neurasthenia, benefited from examples based on clinical experience and research of the Indian investigators.[34]

Based on experience and findings from field testing, the CFI will be included in the DSM-5. We hope that our colleagues who plan to use the DSM-5 in India, North America and throughout the world will find that this cultural enhancement will contribute to better clinical care in a globalizing world, where attention to culture should be a more regular feature of clinical assessment for effective treatment. The contributions to this effort from experience and work in India should not be ignored in a position paper of the Indian Psychiatric Society.