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There is a need for clinical tools to identify cultural issues in diagnostic assessment. To assess the feasibility, acceptability and clinical utility of the DSM-5 Cultural Formulation Interview (CFI) in routine clinical practice. Mixed-methods evaluation of field trial data from six countries. The CFI was administered to diagnostically diverse psychiatric out-patients during a diagnostic interview. In post-evaluation sessions, patients and clinicians completed debriefing qualitative interviews and Likert-scale questionnaires. The duration of CFI administration and the full diagnostic session were monitored. Mixed-methods data from 318 patients and 75 clinicians found the CFI feasible, acceptable and useful. Clinician feasibility ratings were significantly lower than patient ratings and other clinician-assessed outcomes. After administering one CFI, however, clinician feasibility ratings improved significantly and subsequent interviews required less time. The CFI was included in DSM-5 as a feasible, acceptable and useful cultural assessment tool.

Stigma contributes to a significant part of the burden of schizophrenia (SCZ), therefore reducing false positives from the diagnosis would be liberating for the individuals with SCZ and desirable for the clinicians. The stigmatization associated with schizophrenia advocates the need for high-precision diagnosis. In this study, we present an ensemble learning-based approach for high-precision diagnosis of SCZ using peripheral blood gene expression profiles. The machine learning (ML) models, support vector machines (SVM), and prediction analysis for microarrays (PAM) were developed using differentially expressed genes (DEGs) as features. The SCZ samples were classified based on a voting ensemble classifier of SVM and PAM. Further, microarray-based learning was used to classify RNA sequencing (RNA-Seq) samples from our case-control study (Pune-SCZ) to assess cross-platform compatibility. Ensemble learning using ML models resulted in a significantly higher precision of 80.41% (SD: 0.04) when compared to the individual models (SVM-radial: 71.69%, SD: 0.04 and PAM 77.20%, SD: 0.02). The RNA sequencing samples from our case-control study (Pune-SCZ) resulted in a moderate precision (59.92%, SD: 0.05). The feature genes used for model building were enriched for biological processes such as response to stress, regulation of the immune system, and metabolism of organic nitrogen compounds. The network analysis identified , and as hub genes. In summary, this study developed robust models for higher diagnostic precision in psychiatric disorders. Future efforts will be directed towards multi-omic integration and developing \"explainable\" diagnostic models.

Development of the cultural formulation interview (CFI) in DSM-5 required validation for cross-cultural and global use. To assess the overall value (OV) of CFI in the domains of feasibility, acceptability, and utility from the vantage points of clinician-interviewers, patients and accompanying relatives. We conducted cross-sectional semi-structured debriefing interviews in a psychiatric outpatient clinic of a general hospital. We debriefed 36 patients, 12 relatives and eight interviewing clinicians following the audio-recorded CFI. We transformed their Likert scale responses into ordinal values - positive for agreement and negative for disagreement (range +2 to -2). We compared mean ratings of patients, relatives and clinician-interviewers using nonparametric tests. Clinician-wise grouping of patients enabled assessment of clinician effects, inasmuch as patients were randomly interviewed by eight clinicians. We assessed the influence of the presence of relatives, clinical diagnosis and interview characteristics by comparing means. Patient and clinician background characteristics were also compared. Patients, relatives and clinicians rated the CFI positively with few differences among them. Patients with serious mental disorders gave lower ratings. Rating of OV was lower for patients and clinicians when relatives were present. Clinician effects were minimal. Clinicians experienced with culturally diverse patients rated the CFI more positively. Narratives clarified the rationale for ratings. Though developed for the American DSM-5, the CFI was valued by clinicians, patients and relatives in out-patient psychiatric assessment in urban Pune, India. Though relatives may add information and other value, their presence in the interview may impose additional demands on clinicians. Our findings contribute to cross-cultural evaluation of the CFI.

With no disease modifying treatments available, the World Health Organisation’s (WHO) Global Action Plan on the Public Health Response to Dementia emphasises developing effective, low cost, and contextually appropriate strategies for reducing risk and delaying or preventing dementia onset and progression. DEMENTIA AND RESEARCH PRIORITIES To align research investment to the above agenda, in 2015, several of our authors assisted the WHO in a study that mobilised experts and stakeholders from a wide range of disciplines and sectors (including funders, policy makers, professional, and civil societies) in 39 countries to set health research priorities to reduce the global burden of dementia by 2025 [5]. While the top research priorities focused on prevention, risk reduction, and on the delivery and quality of care for people with dementia and their caregivers, other priorities also included research in the development of cross-cultural diagnosis, biomarkers, and treatment, as well as improving public awareness and understanding of dementia. Develop contextually appropriate tools and conduct research to assess early and mid-life risk exposures to dementia, gaps in policy and health services delivery, and public sentiments toward dementia; Develop and apply novel, low-cost methods for analysing biomarkers of brain changes in pre-clinical populations across different language and cultural groups; Develop and pilot contextually appropriate m-health, e-health, and AI tools for early dementia prevention, detection, and intervention; Generate information to identify investment priorities on dementia; Strengthen the evidence base for integrating the experience of people living with cognitive impairment and dementia, as well as caregivers, into public policy; Develop a “global data science platform” to enable data sharing from diverse sources that could be used to study dementia in greater detail especially focussing on cognitive decline across different groups and contexts globally; Develop public health approaches for dementia risk reduction and prevention, and “personalised preventive medicine” at low cost; Identify policies and strategies to promote healthy brain ageing and create dementia friendly environments; and, Develop global, generic guidelines for equitable access to dementia prevention and management (and future cures) that are contextually adaptable across geographies and cultures JOGH-JOGHR THEME ISSUE ON GLOBAL DEMENTIA To mark the beginning of the GloDePP collaboration, we developed this theme issue on global dementia.

Depression, though generally episodic, results in lasting disability, distress, and burden. Rising prevalence of depression and suicide in the context of epidemiological transition demands more attention to social dimensions like gender related stresses, dysfunction, and their role in outcome of depression. Cross-sectional and follow-up assessment of men and women with depression at a psychiatric tertiary centre was undertaken to compare their illness characteristics including suicidal ideation, stresses, and functioning on GAF, SOFAS, and GARF scales (N=107). We reassessed the patients on HDRS-17 after 6 weeks of treatment. Paired t-test and chi-square test of significance were used to compare the two groups, both before and after treatment. Interpersonal and marital stresses were reported more commonly by women (P<0.001) and financial stresses by men (P<0.001) though relational functioning was equally impaired in both. Women had suffered stresses for significantly longer duration (P=0.0038). Men had more impairment in social and occupational functioning compared to females (P=0.0062). History of suicide attempts was significantly associated with more severe depression and lower levels of functioning in case of females with untreated depression. Significant cross-gender differences in stresses, their duration, and types of dysfunction mandate focusing on these aspects over and above the criterion-based diagnosis.

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, 5 th edition (DSM-5).

Objective This study’s objective is to analyze training methods clinicians reported as most and least helpful during the DSM-5 Cultural Formulation Interview field trial, reasons why, and associations between demographic characteristics and method preferences. Method The authors used mixed methods to analyze interviews from 75 clinicians in five continents on their training preferences after a standardized training session and clinicians’ first administration of the Cultural Formulation Interview. Content analysis identified most and least helpful educational methods by reason. Bivariate and logistic regression analysis compared clinician characteristics to method preferences. Results Most frequently, clinicians named case-based behavioral simulations as “most helpful” and video as “least helpful” training methods. Bivariate and logistic regression models, first unadjusted and then clustered by country, found that each additional year of a clinician’s age was associated with a preference for behavioral simulations: OR = 1.05 (95 % CI: 1.01–1.10; p  = 0.025). Conclusions Most clinicians preferred active behavioral simulations in cultural competence training, and this effect was most pronounced among older clinicians. Effective training may be best accomplished through a combination of reviewing written guidelines, video demonstration, and behavioral simulations. Future work can examine the impact of clinician training satisfaction on patient symptoms and quality of life.

Purpose India’s Mental Healthcare Act 2017 provides a right to mental healthcare, revises admission and review procedures, effectively decriminalises suicide and has strong non-discrimination measures, among other provisions. The purpose of this paper is to examine Indian mental health professionals’ views of these changes as they relate to stigma and inclusion of the mentally ill. Design/methodology/approach The authors held nine focus groups in three Indian states, involving 61 mental health professionals including 56 psychiatrists. Findings Several themes relating to stigma and inclusion emerged: stigma is ubiquitous and results in social exclusion; stigma might be increased rather than remedied by certain regulations in the 2017 Act; stigma is not adequately dealt with in the legislation; stigma might discourage people from making “advance directives”; and there is a crucial relationship between stigma and education. Practical implications Implementation of India’s 2017 Act needs to be accompanied by adequate service resourcing and extensive education, including public education. This has commenced but needs substantial resources in order to fulfil the Act’s potential. Social implications India’s mental health legislation governs the mental healthcare of 1.3bn people, one sixth of the planet’s population; seeking to use law to diminish stigma and enhance inclusion in such a large country sets a strong example for other nations. Originality/value This is the first study of stigma and inclusion since India’s 2017 Act was commenced and it highlights both the potential and the challenges of such ambitious rights-based legislation.

Clinically significant fatigue or weakness is a common but understudied clinical problem in India. The applicability and relevance of Western clinical criteria in this setting are not studied. Alternative criteria sets used in different clinical contexts suggest a range of conditions constituting neurasthenia spectrum disorders (NSDs). We therefore aimed to determine frequency of patients with these complaints in four specialty outpatient clinics of an urban general hospital. We compared the concordance of four diagnostic criteria sets of fatigue disorders among the same patients. Patients from the clinics of Psychiatry, Medicine, Dermatology, and Ayurved were screened for clinically significant fatigue or weakness and assessed for CFS, ICD-10 neurasthenia, DSM-IV draft criteria for neurasthenia, and CCMD-2 neurasthenia. For 352 patients, sensitivity of CDC criteria for CFS (13.4%) was poorest. CFS was most frequent in the Medicine clinic. CCMD-2 criteria were the most frequently met (77.6%) with no significant difference across clinics. Two-way concordance of neurasthenia categories was no better than fair (< or =0.4) and few patients (8.0%) met criteria for all four categories. Four NSD criteria sets identified different clinical subgroups. CFS, considering fatigue and ignoring weakness, was least relevant for identifying NSD patients in these clinics. Poor concordance among the four diagnostic systems studied indicates the need for reviewing the nosology of these disorders. Focus on clinical significance alone is likely to avoid the discordant confusion arising from cross-cultural differences.