the-lancet---culture-and-health.pdf

90 evidence based approaches to practice have long

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90 Evidence- based approaches to practice have long recognised that research evidence and clinical skills alone are not suffi cient to achieve optimum outcomes. Treatment decisions often need risks to be weighed, such as the decision between an aggressive or conservative approach to management of a disease by care provider, patient, and health services and funders. Good quality care should therefore integrate “best research evidence with clinical expertise and patient values”. 91 Even in the narrowest biomedical models of health care some form of cultural competence is needed to frame and present information so that patients can make choices in line with their goals, values, and beliefs Panel 2: Medicalisation of culture and mental health The Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 of the American Psychiatric Association (APA) preserves the omniscience of the caregiver at the expense of the patient’s understanding. Surprisingly, this criticism has been most strongly levelled not by medical anthropologists, 83 but by the British Psychological Society (BPS) in an open letter to the APA: “clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences, which demand helping responses, but which do not reflect illnesses so much as normal individual variation.” 84 In effect, the response shows what the BPS felt to be the potential medicalisation of normal behavioural variation. 85 However, the issue is not just about creating illness from individual variation, but also from cultural variation—where otherwise acceptable cultural ways of thinking are themselves redefined as illnesses. Indeed, much of medical anthropology has been devoted to explaining how cultural practices (eg, states of possession) can provide acceptable cultural mediums for expression of anxiety, loss, and helplessness. 86 This diffi culty has been identified for decades by medical anthropologists, 87 yet psychiatry continues to assume a position of omniscience with respect to cultural diversity. To put it another way, what the BPS accused the new DSM-5 of promoting was the medicalisation of human diversity whenever and wherever symptoms seemed to vary from the DSM’s own cultural norms—ie, where symptoms could be identified as subjectively unique. In short, the BPS was openly accusing the APA of falling victim to its own cultural prejudices by defining as symptoms whatever behaviours did not conform to the dominant North American behavioural model from which the DSM emerged, and by allowing for diagnoses that rely on value-laden, subjective judgments that showed little or no evidence of being caused by biological mechanisms requiring pharmaceutical treatment. What is equally diffi cult is the fact that the DSM’s diagnostic categories, according to the BPS, have no predictive value, 88 leaving as many as 30% of all personality disorders to be characterised as “not otherwise specified”.
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