Transcultural psychiatry: Exploring the assessment and diagnoses of migrants in Denmark
2. Project period:
The data collection is finished and the Ph.D. period will run until March 2019.
Signe Skammeritz, MD, Ph.D. student
4. Supervisors and collaborative partners
The project supervisors include Senior Consultant Jessica Carlsson, PhD (CTP, Mental Health Centre
Ballerup), Professor Erik Lykke Mortensen (University of Copenhagen) and Associate Professor
Marie Nørredam (MESU, University of Copenhagen).
The project is carried out in collaboration with Section of immigrant medicine, Department of
Infectious Diseases, University Hospital Hvidovre (IMK), The Danish Research Centre for Migration,
Ethnicity and Health (MESU), and Psychiatric outpatient clinic Ballerup.
Prevalence of psychiatric diagnoses and diagnostic shifts
In Denmark, as in many other countries, there has been an increase in migrants over time1,2
January 2013, 10.7% of the Danish population consisted of migrants and their descendants
originating from over 200 different countries2,3. Studies have shown that migrants have a higher risk
of developing psychiatric illnesses, such as schizophrenia, compared to the native population4–6
This also applies when migrating from one western country to another7,8. Norredam et al. have
found that refugees are at significantly higher overall risk of having a first-time contact with mental
disorders compared to native Danes9
. The complex interplay between the migration process,
cultural bereavement and cultural identity along with biological, psychological, and social factors is
hypothesized to play a major role in the increased rates of mental illness10
A broad overview of the prevalence of the different mental disorders in all groups of migrants in
Denmark will help us understand the treatment demand and thereby improve the ability to plan the
treatment needed for this vulnerable patient group. A high number of diagnostic shifts in migrants
will potentially reflect a low reliability in the diagnostic processes and a lack of diagnostic precision
in migrant patient populations. A more valid diagnosis will supposedly imply better mental health
care for this group of patients as treatment and care often are determined by the specific psychiatric
Diagnosing mental disorders across cultures
To this date, there is no objective measurement to help clinicians determine a psychiatric diagnosis.
Because of this, diagnostic systems such as the International Classification of Diseases-10 (ICD-10)
and the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), were
developed, and diagnostic tools such as Schedules for Clinical Assessment in Neuropsychiatry
(SCAN), are used to increase the diagnostic validity. Consequently, diagnosing mental disorders can
be challenging, and diagnosing patients across cultures adds an extra dimension to this challenge.
Studies show that migrants are at risk of being misdiagnosed11–13. In clinical everyday life, it is
essential for the clinician to be aware of the cultural context in order to reach a full understanding
and precise diagnosis, which will secure the correct treatment. Studies have pointed out that
sociocultural differences are potentially a source of error in the diagnostic process. Therefore, a greater awareness of sociocultural differences is recommended14–16. It is important to study the
underlying explanations for a potential diagnostic uncertainty in a Danish context, because it could
reduce misdiagnosing and thereby lead to better and more efficient mental health care.
Cultural competence and the Cultural Formulation Interview (CFI)
Cultural competence is the ability to understand and be aware of cultural factors17–19, such as
culturally embedded health beliefs and practices. Cultural factors have a major influence on the
explanatory models of the patients, which are the ways patients behave and think about their
illnesses and the treatments they are offered19–23. The capabilities of the clinician to understand
these explanatory models often determine the patients’ satisfaction with the treatment, the
compliance, and the clinical outcome24,25. Adeponle et al. have shown the importance of the cultural
competence in the diagnostic process, by examining the change of diagnoses following a cultural
consultation, where the clinician used the Outline for Cultural Formulation (OCF) from DSM-IV26
Adeponle et al. reviewed the medical records of 325 patients and found that 49% changed diagnosis
from a psychotic to a non-psychotic disorder after a cultural consultation11,27. This study and others
point to the need for methods and tools that are culturally sensitive28,29
The CFI is a new instrument in DSM-5, which was developed based on the experiences from the
OCF. The CFI is an example of a tool developed to identify and cover the cultural issues and context
of the patient. As far as we know, no research has been conducted on the possible effect of the CFI
on the diagnostic process and planning of treatment. Studies in this area would likely provide the
clinician with important information to help ensure optimal care and a patient-centred approach.
The assessment and diagnostic process of migrant patients with mental health problems are areas
receiving little research attention in Denmark. Consequently, there is a need for more evidence to
ensure a culturally appropriate and patient-centred approach, which will benefit patients, clinicians
and be of socioeconomic value, thus assuring a more effective use of resources in the assessment
and treatment30,31. On the basis of the existing knowledge described below, we will investigate the
psychiatric diagnoses and assessment of migrants in Denmark and whether there are ways to
improve the current practices. The overall aim of this study is to strengthen the knowledge about
the assessment and diagnoses of migrant patients with mental health problems in Denmark and
thereby increase the possibility of improving the mental health care for this group of patients.
This PhD project consists of three sub-studies. In the first study, we will examine whether migrants
have a higher incidence of mental disorders than native Danes, and give an indication of potential
problems with the diagnostic validity in the migrant population. In the second study, we will
examine factors that can influence the diagnostic process and validity. In the last study, we will
investigate a tool to overcome the potential problems with diagnostic validity. The research
questions are as follows:
1. What is the incidence of psychiatric diagnoses among migrants compared to native Danes
and do migrants have a higher number of diagnostic shifts compared to native Danes?
2. Do migrant patients change diagnoses during the course of referral, assessment and
evaluation of the treatment at the Competence Centre for Transcultural Psychiatry (CTP) and
if so, what are the possible causes for the changes?
3. Does the clinician find that the use of the Cultural Formulation Interview (CFI) provides
important information for the diagnostic process and treatment plan?
The research questions are based on the following hypotheses:
1. Migrants have a higher incidence of psychiatric diagnoses than native Danes and migrants
have a higher number of diagnostic shifts than native Danes.
2. A considerable number of migrant patients will change diagnoses during the course of
referral, assessment and evaluation of the treatment at the CTP.
3. The CFI provides important information for the diagnostic process and treatment plan.
7.1 Registry-based study on diagnoses and diagnostic shifts among migrant patients
7.1.1 Number of participants (N)
This study will be based on data retrieved from Statistics Denmark. The data will include all
migrants, but not descendants, living in Denmark during the period from 2003-2013 as well as a
Danish-born comparison group (1:6). The Danish control group is defined as Danish-born by
Danish-born parents in order to exclude descendants of migrants. To obtain information on
refugee and family reunification status, the migrant population identified by Statistics Denmark
will be linked with an existing cohort at Danish Research Centre for Migration, Ethnicity and
Health (MESU), University of Copenhagen, obtained through the Danish Immigration Services.
7.1.3 Description of data and data collection
The personal identification numbers of the population will be cross-linked to the Danish
Psychiatric Central Register (PCR) in order to obtain information on psychiatric diagnoses.
Individuals will be followed from 1 January 2003 until the date of one of the following events: 1)
disease event, 2) death, 3) emigration, 4) end of study (31 December 2013). The PCR contains
data on all psychiatric admissions from 1969, including outpatient contacts32. Only ICD-10
diagnoses will be included and emergency room visits will be excluded because the diagnostic
validity of the short encounters is suspected to be low.
7.1.4 Application/acceptance from the Danish Data Protection Agency, the National
Committee on Health Research Ethics:
The accumulated number of different diagnoses in the two groups will be compared over a
period of 10 years, and the first and last diagnose in the given period will also be compared. This
will give an estimate of diagnostic shifts in the two groups. Regression analyses will be
conducted adjusting for age, sex and socioeconomic characteristics.
7.2 Observational study of the transcultural assessment and treatment at CTP
7.2.1 Number of participants (N): According to the preliminary numbers approximately 120
patients will be included per year.
All patients at CTP that meet the referral criteria and who are not enrolled in an ongoing
randomised controlled trial at the centre will be included in the period from 1 July 2014 to 30
June 2016. The referral criteria at CTP include being an adult (18 years or older), being a migrant
with a mental disorder where cultural issues play a significant role in the development, the
assessment or the treatment of the disorder, or being a traumatised refugee with a traumarelated disorder. The traumatised refugees with Post-Traumatic Stress Disorder (PTSD) are
typically included in an ongoing randomised controlled trial.
7.2.3 Description of data and data collection
Patients will follow the standard treatment procedures at CTP and will be invited to a pretreatment interview with a doctor. The interview includes a clinical assessment, recording of
psychiatric, social and somatic anamnesis, and information about the treatment. ICD-10 and
part of the standardised diagnostic tool SCAN will be applied in the assessment. Both self-ratings
and observer-ratings will be used at the beginning and end of treatment. These ratings include
Hopkins Symptom Check List33,34, WHO-5
35, Sheehan Disability Scale36, GAF-S & GAF-F
HoNOS38. Based on the pre-treatment interview, the doctor will decide if the patient should
continue to a multidisciplinary assessment. A decision will be made at a multidisciplinary
conference on whether the patient should be offered treatment at CTP, and if so, whether a
doctor, psychologist, or a nurse should handle the treatment. Manuals are used for all treatment
provided at CTP, and data is collected in the patient records.
After the multidisciplinary assessment, clinicians will decide upon a diagnosis. Treatment will be
divided into modules 1 (3 months) and 2 (3 months). After module 1 there will be an evaluation
of the treatment and the diagnosis will be revised, and it will be decided whether it is relevant
for the patient to continue to module 2. The referral diagnosis will be revised at three different
times: After the multidisciplinary assessment, between modules 1 and 2, and at the end of
7.2.4 Application/acceptance from the Danish Data Protection Agency, the National
Committee on Health Research Ethics: Yes
The diagnosis will be compared for each patient to evaluate whether diagnostic shifts have
occurred at all, if shifts have occurred within the same diagnostic chapter in ICD-10 or from one
diagnostic chapter to another. The clinician will be asked to note if and why the diagnosis has
The sociodemographic data, self-ratings, and observer-ratings will be used to describe the
mental symptoms, quality of life, social and physical functioning of the patient group.
Information on culturally important issues for the patient will be collected at the assessment.
7.3 Study on the use of the Cultural Formulation Interview
7.3.1 Number of participants (N): 70
70 migrant patients referred to the following clinics will be included from 1 January to 30 June
2016: CTP, Section of immigrant medicine, Department of Infectious Diseases, University
Hospital Hvidovre (IMK) and Psychiatric outpatient clinic Ballerup. IMK carries out somatic
assessments of migrants with complex somatic pathology. A broad recruitment from clinics that
differ in patient groups and services will ensure that results are representative in a larger context
in the Danish health care system.
The inclusion criteria include being an adult (18 years or older), being a migrant, having a mental
disorder, and having given informed consent.
7.3.3 Description of data and data collection
The CFI is a semi-structured interview with a patient version, an informant version, and
supplementary modules to use for in-depth details and specific groups such as children or
refugees. The average time spent on the CFI is between 15 and 25 minutes39. Only the patient
version will be used in this study. During the preparatory phase, the investigator and research
colleagues have translated the CFI into Danish. A pilot study on the translated CFI is carried out
at CTP from May to August 2014.
In the present study, a doctor at the different settings will assess patients and a CFI will be
carried out at a separate time from the ordinary clinical assessment. The doctor will summarise
the CFI in the patient records and note if the information from the CFI changes his or her view
on the understanding of the patients’ symptoms, diagnoses, or the content of the treatment
plan. This information will be collected using a check box model. Any critical additional
information will also be noted.
7.3.4 Application/acceptance from the Danish Data Protection Agency, the National
Committee on Health Research Ethics: Yes
The data collected will be analysed to give a quantitative estimate of the additional information
obtained by using the CFI. After a CFI, the patient will be asked to fill out a questionnaire about
acceptability and satisfaction with the interview. Another researcher in a parallel PhD project
will record some of the CFI interviews for qualitative analysis of the patients’ narratives. The
parallel PhD will also investigate the need for cultural competence among clinicians and the
clinicians’ acceptability and satisfaction with the CFI.
8. Expected results
The results of this study will contribute to the existing knowledge in the field of transcultural
psychiatry and is expected to stimulate further research within a relatively short time. We expect
the three studies to have a synergistic effect in which they each contribute to and support each
other in enhancing the assessment, diagnostic process and treatment in transcultural psychiatry and
thereby improve the mental health of migrant patients. The knowledge obtained in this study may
also result in socioeconomic benefits through more focused, time-effective, and patient-centred treatment30,31,40–42
. If the CFI proves to be a useful tool for assessment, it can be broadly applied
throughout the Danish health care system in a scientifically tested version.
9. Dissemination of results
Four publications are planned:
1. “The incidence of psychiatric diagnoses in migrants compared to native Danes”
2. “Psychiatric diagnostic shifts in migrants compared to native Danes”
3. “Changes in diagnoses during treatment at the Competence Centre for Transcultural
4. “Using the Cultural Formulation Interview with migrants – impact on the diagnostic process
and treatment plan”
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