Cultural differences of immigrants influence the diagnosis of mental illness in the emergency room

The Department of Psychiatry of the University Hospital Vall d'Hebron has conducted a study on the role of culture in the use of coercive measures and diagnosis of mental illness among the different ethnic groups who come to the emergency service of psychiatry. The work concludes that it is necessary to provide psychiatrists with tools and resources to detect mismatches in diagnosis caused by cultural differences between professionals and immigrant patients.

The study, also led by the group of Psychiatry, Mental Health and Addictions at the Vall d'Hebron Research Institute (VHIR), was conducted in the emergency service of psychiatry of Vall d'Hebron and Hospital del Mar in Barcelona, on 400 foreigner patients and 67 natives, between 2007 and 2015. In order to analyze the relationship between demographic variables of patients and subjective aspects in the reaction of psychiatrists, the researchers took into account various aspects: on the one hand, country of origin, gender and knowledge of Spanish; and on the other, the certainty of diagnosis, the influence of culture and the level of comfort of the specialist during the interview.

Dr. Francisco Collazos, who led the study, says that in the first visit of a patient to the emergency department of psychiatry, communication with the specialist plays a key role, since they do not have bioassays as a marker that may indicate that the patient has a disease or another. "Shortly we must determine whether the patient can go home or has to stay admitted, according to some behaviors, about expressed emotions and ideas that we have to interpret," explains the researcher. "And this way of expressing emotions, to make sense, for example, the experience of hearing voices, varies widely between the Western discourse that we know, compared to other regions," he says.

This may explain, according to the doctor, why in the study Asians and Eastern Europeans were diagnosed with anxiety up to 7 points more than the native population, or immigrants from Latin America were less diagnosed with psychosis compared to the local population.

Influence of language in diagnosis

In this first interview, conducted by the psychiatrist with the patient, mastery of language plays a key role. According to the study results, patients with the lower level of Spanish understanding and expression were diagnosed with psychosis up to 2.7 times more than those with a higher level.

In the same vein, the study also concluded that the use of coercive measures - such as involuntary admission and presence request of security staff- and intramuscular medication is multiplied by four when communication is not fluent.

Measures to improve cultural competence

Every day go past the emergency room of psychiatry at Vall d'Hebron between 15 and 20 patients on their first visit, 1 or 2 of whom are immigrants. The hospital has a service of intercultural mediators, consisting of 4 people of different ethnicity, who are attending one or two mornings a week to service the entire hospital. When this service is not available, psychiatrists can call Catsalut, which is responsible for putting them on the phone with a translator through the service "Sanitat Respon".

According to Dr. Collazos, the study results show that current resources are insufficient. "We have to adapt resources to the cultural diversity of users, because if we do not do so, the risk we have of offering a lower quality care is much higher."

To change this situation, researchers from Vall d'Hebron are working with psychiatrists at Massachusetts General Hospital, from Harvard University. Their aim is to repeat the study in a larger sample and over a period of 5 years to develop and validate a brief interview that takes into account the cultural disparity of each group. Given the proximity to Morocco and experience with patients in this region, VHIR researchers conducted the questionnaire for this group.

In addition to this project, Dr. Collazos argues that training in cultural competence is needed, since the same study revealed that "health care professionals do not have adequate awareness of the influence that culture has in the care process". It can be explained, in his words, because medical schools do not talk about the influence of culture on the perception of health.

This study has been awarded in the last congress of the European Association of Psychiatry, held a few days ago in Madrid.