Tim's Journal: Roberto Lewis-Fernandez and the New DSM-5 Interview

Dr. Roberto Lewis-Fernandez, who heads the NYS Center of Excellence for Cultural Competence and Hispanic Treatment Program, participated in the panel that put together the new psychiatric diagnostic manual, the DSM-5.

I had the opportunity to meet him at Columbia University’s annual Schizophrenia Conference in April, and did a follow-up interview with him about one aspect of the new manual that has largely been overlooked in media reports about the DSM-5: The new cultural formulation interview.

The updated version of the psychiatric diagnostic manual used by doctors includes a step-by-step cultural formulation interview designed to help take into account cultural information that in the past was often overlooked, according to Dr. Lewis-Fernandez.

“There can be a mismatch between what the patient is saying and what the doctor is trained to hear,” Dr. Lewis-Fernandez said. The new cultural formulation interview—a set of standardized questions--is aimed at closing that gap.

He said he has found that “cultural information enhances validity and clinical usefulness of diagnostic practice.”

Dr. Lewis-Fernandez defines culture as “the water in which we swim.” It is complicated by the fact that “people who look the same can be culturally different.”

Culture, he said, “affects everything about how we think about illness and how we think we should be treated.” He said “we need to be taking that into account in diagnosis.”

The cultural formulation interview consists of 16 standardized questions in four sections and is used at the beginning of the initial evaluation. It is a person-centered approach that is applied to all patients.

The cultural formulation interview was tested in sites throughout the world to see how its use would be accepted by both clinicians and patients. Clinicians generally agreed that it was effective, while patients had an even more positive view of the tool.

Dr. Lewis-Fernandez hopes the new approach will bring about better diagnosis, putting doctors in a “better position to reach appropriate treatment.”

At the May conference of the American Psychiatric Association, several symposia were presented on the questionnaire. Dr. Lewis-Fernandez said reception there was very positive.

“I don’t think we had a single negative comment,” Dr. Lewis-Fernandez said. “Psychiatrists liked the idea of a systematic approach.”

Sally Satel of the American Enterprise Institute said the questions would work well with all patients regardless of their cultural background. “I think they are an excellent set of questions that apply to all patients,” she said.

Dr. Lewis-Fernandez said the hope is that the training used in the field study of the cultural formulation interview can be turned into a standard training component that can be rolled out nationally. The new evaluation tool can then eventually become standard practice by psychiatrists nationwide.

The goal is to make the new section a widely used tool that will help overcome misdiagnosis due to cultural factors.